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5 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is herebymade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TNs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> OS-0 City Lot Size 0� PM <br /> Owner's Name <br /> S Address Phone �_ <br /> Phone No. ti <br /> Contractor's Name License t � <br /> TYPE OF WELLIPUMP; NEW WELL.❑, - -- - WELL REPLACEMENT DESTRUCTION-W, V <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ O <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 /> i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> EI Domestic/Private ❑`G�aJel Paek ❑ Tracy Type of Casing Specifications <br /> " Type of Grout <br /> L] Public { ❑ Other � ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation --Approx..Depth ❑ Eastern Surface Seal.installqd,by <br /> Repair Work Done ❑ Type of?timp H.P. State Work Done _ <br /> Well Destruction ❑ Well-Diameter Sealing Material (top 50') ---- -- <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 1 g available within 200 feet.) <br /> L <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/Mfg' Capacity No. Compartments <br /> � `a ; ,r•_,_.. Method of Disposal <br /> PKG. TREATMENT PLT.:❑ ­-4-- 4- -;w e, r <br /> 1l" Distance to nearest: Well _ " t ' Foundation Property Line , <br /> LEACHING LINE <br /> 'No., Length of lines ' ' - Total length/size <br /> FILTER BED 10 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS .❑Depth —Size Number <br /> SUMPS ;ODistance�to nearest: Well Foundation Property Line <br /> E 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 Iaws,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 m st call for all required inspec'ons. Complete drawing on reverse side. <br /> (•��/ ate: y <br /> Signed ��p " `' Mn. V Title: a a .t1 <br /> S�2j�/��' y/ ' FOR DEPARTMENT USE ONL � VaX�,� <br /> Application Accepted by c4ba Date Ar a <br /> Pit or Grout Inspection by <br /> I Date Final Inspection by Date �"n �`1kYl1 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Pvt L <br /> AP I' ant- Return all lco�pies to: Environmental Health Permit/Services 160 Hazelton Ave.—RD.-Box.2009, Stk., C 95201 oU <br /> S f'Z Z�d � . V twv ".t l� inr*"O <br /> FEE AMOUNT DUE AMOUNT REMITTED CASHCK I RECEIVED BY DATE PERMIT•`NO• <br /> INFO <br /> • /'1 3-Co D � <br /> + EH 13-24(REV.10183} © . :j <br /> EH 14-28 <br />