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APPLICATION FOR PERMIT <br /> y' 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 /> (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. ''/^� /y <br /> Job Address / � 4f City Size M ezy.,- PM <br /> Owner's Namei� �ss Phone 9?_ <br /> Contractor Addresen /r License No. l � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN4 SEWER LINE DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTUR L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREAtepth <br /> STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing \ <br /> ❑ Domestic/Private ❑ Gtavel Pack` ❑ Tracy of Casing Specifications <br /> F1 Public ❑ Other n Delta of Grout Seal Type of Grout _ `l <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ V <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ �\ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALL ION n REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) ` <br /> Installation will serve: Residence_ Commercial_ Other <br /> rl <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Oq Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 4.4Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation�ry� Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: TellFoundation 2— — Property Line-A> f <br /> SEEPAGE PITS I I Depth 2, Size Number <br /> SUMPS Ll Distance to nearest: Well_ Foundation g 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 Di$trict. <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 inspections. Complete drawing on reverse side, <br /> Signed XLJera. �� - —Jfi+ Title: Date: <br /> dr - FOR DEPARTMENT USE ONLY / ��j <br /> A plication Accepted by DaterC/ Q n Area <br /> Pi or Grout Inspection) by Date / ' Final Inspection by -` \Da{e�� <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 INFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY / DATE {� PERMIT/NO. <br /> EH 13-24(REV.iixs) 7® <br /> EH 104-28 <br /> f <br />