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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 1 YEAR FROM DATE ISSUED <br />,A • 1 <br />' <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 <br />made H compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San <br />Local Health District. application is <br />Joaquin <br />Job Address C ,14 t-� > > n <br />City L'��PM <br />Lot Size(�>f� <br />A- <br />Owner's Name �� '� , . �/�� �. _ _ l <br />ess <br />Contractor's Name <br />License No. <br />NEW wci i n <br />Phone 3 <br />1361...._ <br />PUMP INSTALLATION ❑ WtLL REPLACEMENT ❑ ---- <br />DESTRUCTION ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ <br />---_ SEWER LINES DISPOSAL FLD. <br />FOUNDATION AGRICULTURE WELL PROP. LINE <br />INTENDED USE TYPE OF WELL OTHER WELL PITS/SUMPS <br />❑ Industrial PROBLEM AREA CON <br />❑ Domestic/ Private <br />❑ Public <br />❑ Irrigation <br />Destruction <br />Pfr <br />❑ Open Bottom STRUCTION SPECIFICATIONS <br />❑ Manteca Dia. of Well Excavation <br />❑ Gravel Pack ❑ Tracy Type of Casing` <br />❑ Delta Depth of Grout Seal <br />—Approx. Depth ❑ EasternSurface Seal Installed by <br />Type of Pump H P <br />Well DiameterState Work Done <br />Depth _ <br />Sealing Material (top 50') <br />Filler Material (Below 50') <br />NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRI111Tinm r, ,. <br />Installation will serve: Residence _ Commercial _ Other <br />Number of living units: N <br />Dia. of Well Casing <br />Specifications <br />Type of Grout_ <br />c system permitted if public sewer is <br />within 200 feet.) <br />mber of bedrooms <br />Character of soil to a depth of 3 feet:SEPTIC TANK ❑ Type/Mfg Water table depth <br />- <br />PKG. TREATMENT PLT. ❑ Capacity N <br />Distance to nearest: <br />LEACHwr i inic <br />Li 1110. & Length of lines <br />FILTER BED ❑ Distance to nearest: <br />o. Compartments <br />WellMethod of Disposal <br />Foundation property Line <br />_ Total length/size <br />Well Foundation <br />Property Line <br />SEEPAGE PITS ❑ Depth <br />SUMPS Size <br />❑ Distance to nearest: Well Number <br />DISPOSAL PONDS ❑ Foundation Property Line --__ <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />rules and regulations of the San Joaquin Local Health District. <br />Home owner or licensed agent's signature certifies the following:q n county ordinances, state lam <br />employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting "I certify that in the performance of the work for which this permit is issued, I shall rn <br />atu <br />certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ <br />tion laws of Cllo nia." g mpens <br />Thea applicant P Y Persons subject to workman's compenso <br />PP t call for req in cions. Complett3 drawing on reverse side. <br />Signed c�i<' _ , `_ <br />Title: <br />Dater <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by �-,..� G'\ ._.,c,.z�. <br />Pit or Grout Inspection by Date —�S " �'�c Area <br />Date Final Inspection by <br />Additional Comments: Date <br />❑ Stk 466-"31 Lodi 3681 <br />❑ Manteca Service 4 ❑Tracy 83� r _ <br />Applicant -Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 ` <br />FEE I AMOUNT DUE <br />INFO <br />13-24 <br />1426 IREV. 10/831 <br />AMOUNT REMITTED <br />I0 <br />RECEIVED BY <br />DATE PERMIT''NO. <br />o -3-w <br />ti�f - <br />00 <br />