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APPLICATION FOR PERMIT <br /> Mr SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ` <br /> Telephone (209) 466-6781 K 1> b � <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FLS <br /> (Complete in Triplicate) <br /> to t�' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the Nrh re n e48. This ppli on 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 AddressL City Lot Size PM <br /> KOwner's Name e �r I u Address � 1�rtljtq Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/1` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other n 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 ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION I I DESTRUCTIO INo septic system permitted if public sewer is <br /> ",Available within 200 feet.I <br /> Installation will serve: Residence Commercial— Other <br /> 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 /> LEACHING LINE ❑ No. & Length of lines Total lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation 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 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."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 Calif <br /> The applicant call for all required ins ions. Com late drawing on reverse side. <br /> X Signed X Title: <br /> �Id'4 aZ 44 i Date: <br /> FOR DEPARTMENT USE ONLY ) r <br /> Application Accepted by _� -2 ►� o�a.dr~+A� Date Area {` <br /> Pit or Grout Inspection by Date Final Inspection by Date r <br /> Additional Comments: &CIrk 11gLJ c7 a V 4 /fr .e 1 d k-eve_r 5E 5w�& <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Menteca 82.3-7104 ❑ 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 <br /> INFO MOUNT DUE AMOUNT REMITTED H RECEI ED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.t/n51 <br /> EH 14-26 l/ <br />