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APPLICATION FOR PERMIT <br /> y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {209} 466-67$1 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applicin ation 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 compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. or No. 1862 for well/pump and-the Ryles and Regulations of the San Joaquin <br /> ����* �•� ��' <br /> Job Address - <br /> City Lot Size PM <br /> Owner's Name t -?� � yt✓1� _ Add ''�� (�ivLCt tt-t c 7� ca Phonep � <br /> Contra100 Address ` �u�w License No.�� �� ''( <br /> TYPE OF WELL/PUMP: NEW WELL ❑ Phon <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 1 _ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom 5 Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> X-pomestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specifications � <br /> El Public ❑ Other ID Delta Depth of Grout Seal <br /> ❑ Irrigation Type of Grout <br /> ---Approx. Depth ❑ Eastern `Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pumper H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 rn�� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial Other available within 200 feet.) �' <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: fc� <br /> _ _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg w Capacity No. Compartments _ <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal �1 <br /> Distance to nearest: Well Foundation 4 Property Line y. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size umber <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS 12 Foundation Line <br /> I 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 or licensed agent's signature certifies the following: "I certifyrthat 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:"1 certify that in the performance of the work for which this permit Js issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m i c II for all required inspections..Complete drawing on reverse side. <br /> Signe - - - - ­ --- •�- - -- Title:. / <br /> Date: <br /> FOR DEPARTMENT_-USE ONLY` > <br /> Application Accepted by _ --T: T <br /> Date Area <br /> } <br /> Pit or Grout inspection by Date Final Inspection by . �/ <br /> .Data: <br /> Additional Comments: , <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK <br /> INFO �{ CASH RECEIVED SY DATE PERMIT`NO. <br /> 13 i <br /> +EH 24(REV,1/65) `�. <br /> EH 1426 -3L <br />