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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 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. �J A-) <br /> Job Address , �_d� 4CX-W.�T-r A y �CA.[0 City S7�e Lot Size PM <br /> Owner's Name X-7W941A -04S 41 OVAddress Phone <br /> Contractor's Name e,6AX ISH--X"S 16 AIS License No. , _4 Phone yeG <br /> TYPE OF WELL/PUMP;" a NEW WELL ❑ WELL REPLACEMENT .0 DESTRUCTION ❑ C1�� <br /> f PUMP INSTALLATION ❑,_-. ---SYSTEM REPAIR ❑ OTHER ❑ i <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 r Dia. of Well Excavation Dia. of Well Casing ; <br /> ❑ Domestic/Private,. ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> : ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑` WelhOiameter Sealing Material (top 501 <br /> Depth Filler Material {Belo ') ' <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 /> 4 <br /> Number of living units:—6— )Number of bedrooms O <br /> Character of soil to a depth of 3 feet:_[:2\A yWater table depth <br /> SEPTIC TANK ❑ Type/Mfg . Capacity No. Compartments S <br /> PKG. TREATMENT PLT. ❑ Method ofLDisposal <br /> Distance to nearest: Well Foundation Property Line I <br /> 9 <br /> LEACHING LINE ErNo. & Length of,lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> ` it <br /> SEEPAGE PITS iB'/Depth Size 217 Number l <br /> SUMPS ❑ Distance to nearest: Well_AIA Foundation 12 � Property Line <br /> DISPOSAL PONDS D r. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county,ordinance's, state.laws, and; } <br /> rules and regulations of the San Joaquin Local Health District. - ._ t, • 1. ' <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 js`sued,?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 applican st call for all required iris ctions. C mplete drawing on reverse <br /> �. ,�- <br /> Sisnad X� 1— Title: Date: <br /> i i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area F <br /> Pit or Grout Inspection by _ Date Ix��� Final Inspection by Crf�U�'` Date <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE -PERMIT''NO.' <br /> INFO CASH <br /> +EH1324(REV.10183) 1-i �, b O 1i <br /> EH 1126 <br />