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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> W. 14V- <br /> Job Address 5-0 ` City L Lot Size PM <br /> Owner's Name kttj it,&-, Address T Phone <br /> . n <br /> Contractor 0 aa1,/�/,�LG"IC� Address P, 0, Itl/G License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION r u AGRICULTURE WELL OTHER WELL PITS/SUMPS. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom i] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private L Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ irrigation __—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ s <br /> Welt Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will kerve: Residence_ Commercial Other s <br /> Number of living units: Number of bedrooms - <br /> Character of soil to.a depth of 3 feet: - .p PQ;94:5=- T Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity I No. Compartments <br /> PKG. TREATMENT PLT. ❑ � Method of Disposal i <br /> Distance to nearest:- ` 1Nell Foundation ` Property Line <br /> LEACHING LINE ❑ No. & Length o~� f lines"' Total length/size <br /> FILTER BEDDistance to nearest: Well &U0 Foundation Property LineAkv <br /> SEEPAGE PITS ❑ Depth _fK"', SizeNumber _ <br /> SUMPS ❑ Distance to nearest: Well AFoundation! Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner dr licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for.which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call or It required inspections. Complete drawing on reverse side. <br /> Signed X � T Title: 42A_*� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stic 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BYDATE PERMIT'NO. <br /> tEH1}24(FIE:Vrtiasl <br /> EH 14-28 o " CY-1,C11 <br />