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h APPLICATION FOR PERMIT <br /> Lf 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 /> I (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 7. City Lot Size 26,15: y7117 PM <br /> { <br /> Owner's Name _V—PQgAddress -1­0Phone <br /> Contractor's Name " <d 14- License No. <br /> Phone <br /> r TYPE OF WELL/PUMP: :, NEW WELL ❑ WELL REPLACEMENT ❑ Y DESTRUCTION ❑ <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I 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 /> I ❑ Public El Other [IDelta Depth of Grout Seal Type of Grout <br /> S 5 } l <br /> ❑ Irrigation ----Approx. Depth El Eastern Surface Seal Installed by ioy <br /> Repair Work Done ❑ 'Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: A- - Number of bedrooms _ <br /> Character of soil to a depth'of 3 feet: —NVCDQ _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ M <br /> Method of Disposal <br /> Distance-to nearest: Well Foundation ; Property Line <br /> LEACHING LINE No. & Length of lines t <br />!, g Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line' <br /> SEEPAGE PITS i>< Depth & Size sS Number <br /> SUMPS f❑ 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 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 workmari's compensation laws of California."Contractoes hiring or sub-contracting signature <br /> ti 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 st call for all r ed ' spections. Complete drawing on reverse side. <br /> Signed Title: . N' Date: s <br /> s FOR DEPARTMENT USE ONLY <br /> Application Accepted by (_ Date ��- <br /> Pit or Grout Inspection by ate�"a'r Final Inspection <br /> A ditional Comments: <br /> Stk 466-6781 Lodi 369 3621 '=^ ❑ Manteca 823-7104 -❑ Tr y 5-6385 <br /> Applicant- Return all copies to_Environmental Health Permit/Servioes 1601 E. Ha on Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> } <br /> + EH 1 -24(REV.10!831 �pr� C'� 7 <br /> EH 144-7.8711_7 R�S- - <br />