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r} APPLICATION"FOR PERMIT <br /> (/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 . i ��-_0. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED TV-07 <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 <br /> DrY ` v-" City Lot Size PM <br /> v 3 <br /> Owner's Name `gess Phone <br /> Contractor Address License No. f hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION,❑ � <br /> PUMP INSTALLATION LlSYSTEM REPAIR 13t OTHER C] ti <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 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 t ---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 �f <br /> Depth Filler Material (Below 50'} ee� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C1REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> ailable within 200 feet.) <br /> Installation will serve:" ResidencewCommercial­—Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a dept of 3 feet:Water table depth <br /> SEPTIC TANK ' V Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ , t Method of Disposal tj <br /> �4 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of.lines Total length/siie <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> '--'-Prop" Line <br /> k <br /> SEEPAGE PITS ❑ Depth Size Number " <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line" <br /> a 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 certrfy 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 subiect to workman's compensation-laws-of Califomis."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the pe ormance 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 al required i ns. Complete drawing on re <br /> i �yjt <br /> Signed Title: Date: <br /> �. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 1 Area 0 <br /> Pit or Grout Inspection by Datm Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ L�13W�3ra2l �[D �eca �8237104 ❑ 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 K# RECEIVED BY DATE PERMIT''NO. <br /> INFOAMPS <br /> + EEH 1H 13-24(REV. 0 <br /> 426 �J <br /> r <br />