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APPLICATION FOR PERMIT <br />r i SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE T ON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />c <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 />h e.iAl.— ACI " �1!`V 0 7 ! IQ�c� %�L Citv5nq_ <l_a_YLot Size <br />PM <br />Owner's Name i -Address �� Phone 077-- W6F <br />Contractor <br />Address License No. Phone <br />TYPE OF WELL UMP: <br />NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />ATE <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />0-0 <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Industrial <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />❑ Domestic/ Private <br />❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />1-1 Public <br />n Other ❑ Delta Depth of Grout Seal Type of Grout— <br />I I(riiJation <br />_Approx. Depth I I Eastern Surface Seal Installed by <br />Repair Work Done ❑ <br />Type of Pump H. P. State Work Done _ <br />Well Destruction ❑ <br />Well Diameter Sealing Material Itop 501 <br />Depth Filler Material IBelow 50') <br />TYPE OF SEPTIC WORK: <br />NEW INSTALLATION i 1 REPAIR/ADDITION i -I DESTRUCTIO (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: <br />Residence — Commercial Other <br />Number of living units: <br />Number of bedrooms <br />Character of soil to a depth <br />of 3 feet: Water table depth <br />SEPTIC TANK T <br />❑ Type/Mfg . Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />❑ Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE <br />❑ - No. & Length of lines Total length/size <br />FILTER BED <br />❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS <br />i I Depth Size _ Number <br />SUMPS " <br />EI Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS. <br />❑ <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 applica ust call for all require spectf Com fete drawin on reverse e. <br />i <br />Signed �_ Date:��� <br />R DE T.,:USE ONLY <br />Application Accepted by CA_­�. ` Date 9_1 Area <br />Pit or Grout Inspection by DateFinal Inspection by Date <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 />EH 13-24 1 REV. 1 / y 5) <br />EH 1428 <br />FEE <br />INFO <br />AMOUNT DUE <br />OUNT REMITTED <br />CASH <br />RECEIVED BY <br />ATE <br />PERMITNO. <br />0-0 <br />?'3q-711 <br />4k <br />I IN <br />