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APPLICATION FOR PERMIT <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT ry ' <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA C%— Q a <br /> Telephone (209) 466-6781 Q <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 4 <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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address __ 7 17 .rJ-x1,� Q � City _ Lot Size PM <br /> Owner's Name d�,e �o Address __ 'T'� 414­74l�iir l Phone d0 <br /> Contractor, 44_� - <br /> Address 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—T 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 D Tracy Type of Casing Specifications <br /> M Public w C7 Other ❑ Delta Depth of Grout Seal Type of Grout ; <br /> I I Irrigation _Approx. Depth { I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type-of Pump H.P. ` State Work Done <br /> Well Destruction © Well.Diameter Sealing Material Itop.50') <br /> Depth t Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION 1.1 - DESTRUCTIO 1 (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: Number of bedrooms <br /> I <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 Foundation Property Line ; <br /> t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line - <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll 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 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 applicant must all for all required i pecttons. Complete drawing on reverse side. <br /> 1 Signed X Title: <br /> j� bate: _ 7 <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by &Mn Date ._S_ Area <br /> -p <br /> r Pit or Grout Inspection by Date Final Inspection by Date 1 ZJP 1 <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PER;1TNO. <br /> £H 14-26 iREV.t i x 51 > 3 S —.5- ,O !! 00 X� <br /> F <br />