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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 /> Fr <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED q s <br /> (Complete in Triplicate) a <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 —.4 . <br /> Lot Size <br /> _ Owner's NameMFi-7?.-v Adr "Phone <br /> e <br /> �.S ✓t r �f <br /> Contractor's Name ens, No. Phone `r e < <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 *' ,Dia"of WeII Casing <br /> El Domestic/Private C1 Gravel Pack"" '�' ❑~Tracy I _'Type of Casing I Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal # Type of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern I Surface Seal installed by I <br /> CQ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done i <br /> Well Destruction ❑ f Well Diameter ..?.Sealing.Material (top 50') . j <br /> Depth Filler Material (Below ) s x <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Er DESTRUCTION ❑ Mo septic system permitted if public sewer is <br /> + s available+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: ` " —Water table depth , <br /> SEPTIC TANK ❑ Type/Mfg . - r '-- '—Capacity M t No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> � Method of Disposal • <br /> Distan e'tnearest Weil Foundation ° Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size } f <br /> FILTER BED ❑ Distance to nearest: Well Foundation." - Property Line <br /> SEEPAGE PITS ❑ Depth a I It) Lq Size' Number <br /> ❑ Distance to nearest: Well Foundation .Property Line s <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. si <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."Contractors hiring or sub-contracting signature <br /> certifies the fallowing:"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 ust for all requir ' spections. et,drawing on reverse side. <br /> Signed _ Title: !� Date: <br /> v <br /> FOR DEPARTMENT USE ONLY In j <br /> Application Accepted by A Date <br /> Pit or rout Inspection by Date Final Inspection by Data60�la <br /> �J <br /> i <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 CASH RECEIVED BY rr DATE PERMIT"N0. f <br /> EK 14-241REV.101831 _7�� �� �-�� <br /> EH 10.26 / �..� <br /> r <br />