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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA I <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7'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 /> r� C i <br /> Job Address `i"OQ :5,Z) City Lot Size PM <br /> Owner's Name (P& i Address Phone <br /> t dress d c.QSs L'icense No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑'- WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION RG. SYSTEM REPAIR K OTHER ❑ <br /> �. D.ISTANCE_T.O.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE <br /> FOUNDATION 'AGRICULTURE WELL OTH(Ft WELL PITS/SUMPS"`—"'"' <br /> INTENDED USE TYPE.OF WELLS,,w PROBLEM AREA , CONSTRUCTION SPECIFICATIONS <br /> y ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> b I I Irrigation _-.Approx. Depth I 1 Eastern . ,,Surface Seal Installed by - <br /> Repair Work Done Type of-Pump H.P. State Work Done a <br /> Well Destruction ❑ x Well Diameter A Sealing Material�(top 50') C <br /> Depth ' Filler Material (Below 50'1 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> µ 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 rte_ <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments v <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> -.- Distance to nearest: Well Foundation Property.Linnee <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line f <br /> E <br /> 3 SEEPAGE PITS t I Depth Size _ Number <br /> t.. • SUMPS - D Distance-to nearest: Well - Foundation w.. 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: "4 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 /> I� The applicant mu MtoXor all required inspections. Complete drawing on reverse side. <br /> Signed X �A-� ' 4 Title: Date: —/ <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by <br /> FOR Date �. " - Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6791-' r" -❑ Lodi 369-3621`F--El Manteca 823-7104 ❑ Tracy -935-6385. <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I . <br /> PEE AMOUNT DUE AMOUNTREMITTED CK RECEIVED BY DATE PERMIT'NO.�, <br /> INFO !I CASH <br /> 1-7 <br /> +.EH 13-24 tREV.I/n 51 � <br /> t . <br /> EH 14-26 _ <br />