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o APPLICATION FOR PERMIT <br /> SAN J <br /> �l OAQUIN LOCAL HEALTH DISTRICT <br /> U� 1601 E. HAZE 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. <br /> Job Address�/ ��' �� -- City Qry Lot Size PM <br /> — E � i <br /> Owner's Name ess f�P X)a�� 1��� Phone <br /> Y_ <br /> Contractor / Address 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. IPROP. 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 Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation --Approx. Depth I I 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 50') — <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200.feet.) <br /> +� Installation will serve: Residence-/— Commercial_ Other <br /> Number of living units: / Number of bedroorrye 7— <br /> Character <br /> Character of soil to a depth of 3 feet: f� Water table depth o <br /> SEPTIC TANK ❑ Type/Mfg Capacity n No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well raQ Foundation f Property Line,/610 <br /> ry LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ElDistance to nearest: WellFoundation Property line i <br /> O <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LA" 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 /> r� 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 requ ed inspections. Complete drawing on reverse side. <br /> Signed X �C Title: [ 'I� 17'L-1 / Date: .2— <br /> 2 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 4Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date40 <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> 00 0+.EH 13-24(REV.i i x 5) 7 70 <br /> U � 3 �� <br /> EH 14-26 v <br />