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APPLICATION FOR PERMIT 4L <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT S. <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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 /> i <br /> Job Address 119 S d r City S' Lot Size PM <br /> f� 9FOn 4 Phone <br /> Owner's Name, /� Address <br /> Contractor- a Address fO License No. Phone <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 Well Casing <br /> 171 Domestic/Private ❑ Gravel Pack (D Tracy Type of Casing Specifications <br /> F1 Public i1 Other ❑ Delta Depth of Grout Seal Type of Grout-- <br /> I <br /> rout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done �+ <br /> Well Destruction 0 Well Diameter Sealing Material Itop 501 r <br /> Depth Filler Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1: REPAIR/ADDITION I I DESTRUCTION o septic system permitted if public sewer is <br /> a ilable within 200 feet.I <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/MfgCapacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal d <br /> Distance to nearest: i Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total.length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number ; <br /> SUMPS Ll Distance to nearest: Well Foundation z 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, sta41aws, arules 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 issueemploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractngsgnature <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 applicant mu"ll for all required inspections. Complete drawing on reverse side. <br /> Signed XCr)o /Jl�_ /%O _ Title: Date: <br /> " FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date � Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Imo ', ti as �� <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 + ❑ Tr cy 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 C K RECEIVED BY DATE PERMIT h0. <br /> INFO <br /> I <br /> EH 14-2a <br /> ♦ EH 13.24IREV.1/n51 <br /> iJ.J <br />