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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE',-TON.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. , <br /> Job Address City its PM <br /> Owner's Name &J464 e,41-IlAddress ✓ ® one <br /> Z 3 A <br /> Contractor w. } ddress 2 License No./?3 73 Phone v� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ / DESTRUCTION ❑ <br /> PUMP INSTALLA11ON ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDS® OSE T"E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> &-lZmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> D Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation /---Approx. Depth ❑ sternSyLace Seal Installed by 01 <br /> Repair Work Done PI Type of Pump H.P. `9 State Work Done <br /> Well Destruction ❑ Well Diameter j Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is J <br /> available within 200 feet.) <br /> Installation will serve: Residence_ CoLmercial_ Other <br /> Number of living units: Number of�edrooms <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> LA <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 /> G <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearegt: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify th a prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and reg ions of th an Joaquin Local kealth District. <br /> Home own or licensed age '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 a person in such ma per as to beco a subject orkman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies he following: "I certify 1pat in th nc t work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion la s of California." <br /> The a plicant mus c r I requi I ete rawing on rev de. <br /> Signed Title: tol ate: <br /> r <br /> FO&DEPARTMENT USE ONLY <br /> Application Accepted ate tp Area b <br /> Pit or Grout Inspecti y Date Final;Inspection by 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 PermiUServices 1601 E. Halelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTER CCCKSH RECEIVED BY DATE PERMIT'NO, <br /> 113E0 <br /> + EH1324(REV. /e5) ` �o <br /> EH 14-26 O <br /> i <br />