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APPLICATION FOR PERMIT <br /> b SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 City, "— Lot Size PM <br /> to!q,q �/ \ —647-�ddress f�— J� , es_ PhoneOwner's Name r <br /> C tractor t +T itdfeSS - <br /> i� �- >G <br /> Phone i <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUC <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PRO>'� LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'T <br /> .INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �.:DtK --- b <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /a- Dia* of Weil Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of'Casing '- Specifications , .�. <br /> M 1 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation --Approx. Depth ( I Eastern Surf a Seal Installed by4� � <br /> Repair Work Done ❑ Type of Pump J A5 H.P» 1=� �=� -°State Whrk Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 . <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is t <br /> available within 200 feet.) <br /> F,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 /> ?KG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> blSPOSAL 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant or 1 req ui tions. Complete drawing on reve <br /> rsede. <br /> "00Signed X Title: -�J�!'A ^� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b Date 2 4 Area (v <br /> Pit or Grout Ins;h n b Date 3hkk Final Inspection by Date <br /> Additional Comments: <br /> ❑'Stk 466-6781 ❑ Lodi 369-3621 ❑Manteca- 823-7104 ❑ Tracy 835-6385 <br /> Applicant-7.-Beturn.all copies.to: Environmental Health Permit/tenrices 1601,E..Hazelton.Aue., P.O. Box 2009,Stk., CA 910111 <br /> CK 0 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> ��ZQ <br /> a EN 13.24(REV.t/H5) <br /> EH 14-26 <br />