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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—i ON AVE., STOCKTON, CA <br /> -" Telephone"i2O9) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " <br /> g, (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 City <br /> �C � �J fd I �� Xkyp"Oep Lot Sizer a% G'" PM <br /> Owner's Name kP,6 Address J b a — Imo& 1'2S Phone i4c:6 <br /> -ke -1� ! ��-- `2'"Q!� �lY Phone <br /> Contractor �� ���� ddress •Q �� � inseao. <br /> TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS <br /> s <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation 6.11 Dia. of Well Casing <br /> -ADomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing / {c-u g-i r Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal .S-d Type of Growe"'110-QM j <br /> ❑ Irrigation --LApprox. Depth ❑ Eastern Surface Seal Installed by S74rc! 'fir—� <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> I. Depth Filler Material (Below 501 <br /> T-Y-PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ,t available within 200 feet.) <br /> Installation,.wi e: Residence_ Commercial_ Other <br /> Number of,living units: Number of bedrooms <br /> Character of soil to a depth of 3 Water table depth <br /> SEPTIC TANK ❑ Type7ce <br /> Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distao nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No.A& Length of lines, Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation o rty Line <br /> I `SEEPAGE PITS ❑ Depth' Size " r Numbers. <br /> SUMPS ❑ 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." f _ _ _ <br /> Th2tby <br /> ll for all required inspecti ns, eta drawing on reverse side. <br /> SiTitle: � � Date: <br /> + FO DEPART ENT USE ONLY <br /> A x Date / Area <br /> Pit or Grout Inspection by _ Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi` 369-3621 IV❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20p9, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERRMIT'NO. <br /> + EH 73-241REy.1/8S1 70- 00- <br /> 00 <br /> f y / 72 <br /> EH 14-28 N/ <br /> i <br />