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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> y 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 AddressIr Ci t Size PM <br /> Owner's Name LL/Address one ! <br /> r/ + <br /> p C S I <br /> Contractor Address 'P© [ �Q�, 112-1.License No. 2 3 7 3 Phone_ "�96 7, <br /> TYPE OF WELL/PUMP: INEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> Fl­ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 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 /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavatiop. pia. of Well Casing Z <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing a Specifications <br /> ('l Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout—,-- <br /> I <br /> rout _I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done L7Jype of Pump H.P. State Work Doone_ <br /> Well Destruction I—�/Well Diameter Sealing Material (top S&A00 ��J�G�G e eh <br /> Depth .6'0 Q Filler Material (Below;) 1111a rL d <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION t I DESTRUCTION 1 I (No Septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other S <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 /> SEEPAGE PITS - I I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify tha ve ared this application and that the work will be done in accordance with Sar!Joaquin county ordinances, state laws, and <br /> rules and regul ons of the San Joaquin Local Health District. <br /> Home own or licensed agent's gnature 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 manna as to become subjec t w rk n' com s of California." Contractor's hiring or sub-contracting signature <br /> certifie he following: "I certify th t in a perfor an t rk r whi this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion I s of Californi .' <br /> The plicant mus all for all ed ins cti drawing o reverse id <br /> Signed X , '14 16-4600.0 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by c7a <br /> Date / <br /> Pit or Grout Inspection by Date Final Inspection by C✓U Date .v —1 <br /> Additional Comments: ZQ ZZ_. <br /> ❑ Stl- 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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. <br /> +.EH 1 -24(REV.1/x 51 S CX <br /> EH 144-28 <br />