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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> Job Address �J <br /> [� `W- yr City _-17tXZ Lot Size � � PM <br /> �1 <br /> Owner's Name r® Address ^���`� � � y/Iy 6 Phone __L___- <br /> Contractor T Address �a^1�.�,� License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑L OTHER ❑ <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OFA WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F] Public Cl Other Ll Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.-Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 1. ❑ Well Diameter Sealing Material (top.50') <br /> -a4s. f <br /> " Depth ��-"'�'- Filler Material 19elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIR/ADDITION I I DESTRUCTION XINo septic system permitted if public sewer is 1\\ <br /> Iir Navailable within 200 feet.) V <br /> Installation will serve: Residence_ ICo_mmar cial— Other <br /> s Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:` Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Lerigth of lines Total length/size f <br /> FILTER BED ❑ Distance io nearest: Well Foundation Property Line <br /> z <br /> SEEPAGE PITS l I" Depth Size _ Number <br /> SUMPS ❑ .Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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." Contractors 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:pplipprit call f all requ red " spections. Complete drawing on reverse side. <br /> Signd X-74" Title: __ G ( A1/,151C Date: <br /> FOR DEPARTMENT USE ONLY 7 <br /> Application Accepted by Data ` � --r00 Area <br /> Pit or Grout Inspection by _ Date Final Inspection by i/'e' Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Man eca 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 /> I - <br /> ' INFO AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT"NO. <br /> +.EH 1 -211REY.1iN51 U �jAt <br /> C( <br /> � EH 14448 Q (J <br />