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APPLICATION FOR PERMIT <br /> 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 Districts <br /> Job Address v� J l`i( s City TUC pfd At Lot Size t*�Q Y,500 PM <br /> Owner's Name Address L'� �Q(j'GL VAI <br /> 2- <br /> Phone <br /> Contractor's Name . -fel-o '/i- License No. <br /> TYPE OF WELL/PUMP: Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ^—g <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 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 /> ElDomestic/Private ❑ Gravel Pack El Tracy Type <br /> of Well Casing <br /> of Casing Specifications <br /> El Public ❑ Other ❑ Delta Depth of Grout Seal <br /> El Irrigation Type of Grout <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 "C <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.) Q <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth r� <br /> ❑ Type/Mfg Capacity No. Compartments V i <br /> PKG. TREATMENT PLT. ❑ <br /> � Method of Disposal S' <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size � <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> SUMPS <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ElProperty 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 cap fo quired inspections. Complete drawing on reverse side. <br /> C <br /> Signed E Title: <br /> Date: <br /> A 1� FOR DEPARTMENT USE ONLY ` r <br /> Application Accepted by \ SZ AA&A �,eeej!-� Date 2- '\ b <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by 4)Cl-- . <br /> 'Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> 121 <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# <br /> INFO CASH RECEIVED BY E PERMITNO. <br /> EH 1 <br /> + EH 13-24(REV. 10/83) / �! (� �,.y�^ a_r DATE B y_ 1S9 <br /> 428 �1{ / „ <br />