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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 9 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. <br /> / <br /> Job Address SiV City Lot Size PM <br /> Owner's Name LJ r Address Phone T <br /> Contractor's Nam License No. �� ®��_� Phone o <br /> TYPE OF WELL/PUMP: NEW WELL W WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION kf SYSTEM REPAIR ❑ OTHER ❑ <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 Jr r� <br /> ❑ Industrial E3 Open Bottom C1 Manteca Dia. of Well Excav��a--t-i^o�nn--�� Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing A1C . Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal t'Q Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump sI A 13 W H.P, f State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material IBelow 501. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo 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 /> 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 /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> J <br /> SEEPAGE PITS ❑ Depth Size Number <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."Contractors 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 Califor ' :" <br /> The applicant t call for all required i spection omplete drawing on reverse side. �,( r <br /> Signed Title: �?Y 4W I Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> q q p � <br /> Pit or Grout Inspection Date to Final inspec' n by ate A <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lod, 369-3621 ❑ Manteca 623-7 4 <br /> ❑ Trac 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haze on Ave., P.O. Box 2009, Stk., CA 95201 <br /> ,•� ICK W N1� wo s orl vaca- on <br /> FEE A PUNT DUE OUNT REMITTED RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> �1-7 -9 3 <br /> +EH 13-241REV.10183) <br /> EH 1426 g O 1 S /T;"5S-5 —ct 3 <br />