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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT p <br /> 1601 E. HAZELTON AVE., STOCKTON, CA J <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SCANNED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constructend/or install the work herein described. This application is <br /> made in compliance with San Joaquin Cou ty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health D' ictt:t/ <br /> / /�/ev <br /> Job Addressity � Lot Size pM <br /> Owner's Nam V ddress <br /> PhoneContractor's . License No. 357e ? Phone _17J <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 E Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ 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 501 <br /> Depth Filler Material (Below 50' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION WINo septic system permitted if public sewer is <br /> available within 200 feet.) 8 <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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well FF01.111179Wn Property Line 1L <br /> r <br /> LEACHING LINE ❑ No. & Length of lines — ' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed ent'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 manner as to become sub ct to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the folbwin " certify that in the pert -e of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif <br /> The ap call for all re omp a drawing o e side. <br /> Si T.1 - – <br /> Date: <br /> OR DEPARTMENT USE ONLY � "� <br /> Application Accepted by Date /K B` Area <br /> Pit or Grout Inspection by Date Final Inspection by � z1n+-�-4,G" Date <br /> . ,b1 ( <br /> Additional Comments: – Y n QVw .,� � L(L�-7 <br /> ❑ Stk 466x781 ❑ 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 2008, Stk., CA 95201 <br /> FEE ff <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEEHEH X24(REV.10/83) 3 Q O /' 7 5- <br /> E �s7 2bFr <br />