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APPLICATION FOR PERMIT 1/r _7d <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 <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 Regulation of the San Joaquin <br /> Local Health District. -Ino_ <br /> G 9 0 - — (� Ll <br /> Job Address -? City Lot Size 20 <br /> PM Cj <br /> Owner's Name -re&M ! Address Phone / <br /> Contractor's Name Vi icense No. Phone — - 3 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER El !- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> `Domestic/Private 13Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth Eastern Surface Seal Installed by <br /> Repair Work Done ElType of PumpAH.P. Stat Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) <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 /> PKG. 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 ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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,)shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call fo all requiredinspec ions. Complete drawing on reverse side. <br /> J. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY 107 ! r� <br /> Application Accepted by Date / �/ 7 Area <br /> Pit or Grout Inspection by Date Final Inspection by ` Date 7- <br /> Additional CommenXcopies:�: <br /> ❑ Stk 466-6781 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AM <br /> INFO OUNT DUE AMOUNT REMITTED <br /> CASH RECEIVED BY DATE PERMITNO. <br /> + EH 13-24(REV.10/83) G{ �J f r� '-'735 �M -7^l l�qP� (]�� <br /> EH 14-26 / `-r [ J V lXJ <br />