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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />�t 1601 E. HAZE T ON AVE., STOCKTON, CA <br />' Teiephone (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. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address _ .[/ <br /> w <br /> Cityize PM <br /> Owner's Name � _�L Address CS - <br /> Phone <br /> ' a <br /> Contractor - LL Address 1. ry S� I <br /> License No. 5.Phone E <br /> T PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑" ""SYSTEhA REPAIR ❑ P OTHER ❑ <br /> DISTANCE TO NEAREST: NK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE STRUCTION SPECIFICATIONS zCy <br /> -O Industrial ❑ Open Bottom. ❑ Manteca Dia. of We vabon <br /> Dia. of Well Casing - - <br /> ❑ Domestic/Private. ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation _meq Type of Grout <br /> --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Pepair Work Done ❑ Type of Pump T H.p. State Work Done <br /> Well Destruction ❑ Well Diameter jSealing Material (top 50') <br /> Depth Filler Material (Below 501 V1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ES I KUCTION ❑ (No septic system permitted if public sewer is U <br /> Installation will serve: Residence` available within 200 feet.)Commercial Other r <br /> Number of living units: 4— Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK9?"-Type/Mfg C Capacity No..Compartments <br /> PKG. TREATMENT PLT. El Method of Disposal <br /> Distance to nearest: Well _ Foundation Property Line <br /> Pubb <br /> LEACHING LINEN 61--No. & Length of lines a( Total length/size 14 tD <br /> FILTER BED ,,i ::, `❑ ' Distance to nearest: Wel! Foundation Pro <br /> perry Line <br /> ..SEEPAGE PITS a 'I-L—Depth Size <br /> � t � Number . <br /> SUMPS ❑ Distance to nearest: Well Foundation .= Property Line i <br /> DISPOSAL PONDS 0 T L <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 1 <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 /> c J., the foil lifo ng:.';I _ ify that in the performance of.the,work for which this permit is issued,1 shall employ persons subject to workman's compensa <br /> tion of California." <br /> The applican st call for all equi ins ction o late dra g on re,Kerse side. <br /> Sign <br /> it a:-- - Date: <br /> FOR DEPARTMENT USE ONLY <br /> plication Accepted <br /> Date �? <br /> `LArea 7 <br /> Pit r Grout lnspectio y date - r :Final Inspection by <br /> 6Date lh <br /> Additional Comments: <br /> ❑ Stk 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 l <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED += <br /> INFO CA RECEIVED BY PERMIT'NO, i <br /> + EH 13.24 MEV.1/6 5) <br /> EH 14-28 �.. �. � <br />