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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209h 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health i <br /> D/sstrc/t. y��7 <br /> X .4 Le <br /> Job Address / ! 0CJCity Lot Size r PM <br /> Owner's Name.!�Ir- ` .�] , Address ! C y fA�% f r� <br /> e-? �t! Phone <br /> Cantrac rr, Address / `r License No_ 2�� �� l <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT 11 DESTRUCTION E <br /> PUMP INSTALLATION [I 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 /> ❑ Industrial Cl Open Bottom Ci-Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> f Domestic/Private 1-- Gravel Pack El Tracy Type of Casing Specifications <br /> F! Public l Other F1 Delta Depth of Grout Seal _ <br /> Type of Grout <br /> Irrigation Approx. Depth I i Eastern Surface Seal Installed by r" <br /> Repair Work Done 11 Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'Y <br /> Depth Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INS�TAALLLLATION REPAIR! DDITION j DESTRUCTION t i (No septic system permitted if public sewer is <br /> Installation will serve: Res-dente' Commercial Other available within 200 feet.) <br /> Number of living units: Number of edrooms.s <br /> Character of soil to a depth of 3 feet- _-' <br /> SEPTIC TANK Water table depth <br /> C7 Type/Mfg 1 � Capacity_. No. Crtments <br /> ompa <br /> PKG. TREATMENT PLT. (] E/ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line <br /> - <br /> LEACHING LINE <br /> No. & Length at lines - _! Total length/size r / <br /> FILTER BED f7 Distance to nearest: Well Foundation11 <br /> ! - — Property Line � <br /> SFEPAGE PITS Depth <br /> SUMPS r Number_ <br /> L ! Distance to nearest: Well Foundation _- <br /> DISPOSAL PONDS > Property Line <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." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which thisem to <br /> ermit is issued, I shall <br /> tion laws of California." /1' p employ persons subject to workman's campensa <br /> The applican st calf foo( Jquira inspections. Complete drawing on reverse si e. ii <br /> Signed X <br /> Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Ap ication Accepted by Z <br /> I Dare � Area <br /> i or Grout Inspection by <br /> L Final lnspectian by Date J <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 <br /> FEE <br /> INFO MOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED 13Y DATE PERMIT NO, <br /> + EH 13-24(REV,i i 4 5i <br /> EH 14-28 <br />