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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 77Z, 0 4AI19R <br /> City �/` Lot Size 1 PM <br /> Owner's Name 1 G-� v► I_L C' ' <br /> ^ 1 r Address Phone <br /> Contractor c 1 'C . ,Address 5 <br /> License No. Phone <br /> TYPE OF WELL/PUMP: 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> F: Irrigation _� Type of Grout <br /> ---Approx. Depth Ll 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 501 <br /> Depth Filler Material 1Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200 feet.) <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: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Wel! Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size- <br /> -FILTER BED ❑ Distance to nearest: Wel! Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> SUMPS ElDistance 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 this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required ins <br /> ction} complete-drawing on reverse side. - ) F <br /> Signed Ti#le: �f7��=.� / <br /> Date: <br /> } FOR DEYARTMENT USE ONLY <br /> Application Accepted by V ` Date - 14 1\/\ <br /> Pit <br /> Pit or Grout Inspection by Date Final I tion b / <br /> t <br /> Date 16 <br /> `Ad�itional Comments: <br /> p�Stk 466-6781 7 odi 369-3621 F-1638,5 <br /> Manteca 823-7104 ❑ Tracy 835, <br /> //'Ap��`��`Ocant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K <br /> INFO '] CASH RECEIVED BY DATE PERMIT N0. <br /> + EH 13-24 IREV. <br /> EH 14-28 C <br />