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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. ��*+ <br /> Job Address o <br /> City 99.21-�Lot Size PM <br /> Owner's Name � r ;,1"z, E_ � Address i) �1 : t, �d»C�r.�'i Phone <br /> Contractor Address License No. ? S�o Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0. <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca 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 L <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler_Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW 4NSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial 4!!!� Other <br /> Number of living units: Number of bedrooms 1 <br /> Character of soil to a de th of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mf12j a 1.+74 Capacity /�ti _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to lnearest: Well Foundation Property Line <br /> LEACHING LINE 0--No. & Length of lines 'A"4 <br /> Total length/size <br /> FILTER BED ❑ Distance to,nearest: Well Foundation 3e) � r Property Line <br /> r <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."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 must call for 1 required inspections. Complete drawing on reverse side. <br /> Signed X. ' Cc' - �.�'�-� Title: .. . Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ``� �• r Date LZ <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Data(---2 <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 REMITCK <br /> TED <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.ties! <br /> EH 14.26 ^76 b/3��10 ^St0 <br /> 0 / <br />