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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES '(`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. ON <br /> Job Address 0 J4 <br /> p City Lot Size PM <br /> Owner's Name C� �I �+ <br /> Address 3 v14 <br /> ice . Phone <br /> - r I -�p.� <br /> Contractor44gII Address •V. License No.2 5E Phoney IaS�J <br /> TYPE OF WELL/PUMP: NEW WELL D ___-_ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION O _ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK i _ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION a AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 00 pen Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ 'Tracy Type e of Casing ¢ <br /> Specifications <br /> * r7 Public C] Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation <br /> --Approx. Depth l I Eastern N Surface Seal Installed by 3 <br /> Repair Work pone E3 Type f Pump H.P. -- State-Work-Done _ <br /> Well Destruction ❑ Well Diameter ' Sealing Material (top 50') i <br /> DeptAl Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 111 REPAIR/ADDITION l ], DESTRUCTION INa septic system permitted public sewer is <br /> Ifavailable within ee . <br /> Installation will serve: 'Residence Commercial— Other 1 <br /> f � W <br /> Number of living units: Number of�edrooms <br /> Character of soil to a depth ofl� feet: I Water-table depth'No. Compartments <br /> Yp 9 Capacity <br /> SEPTIC TANK ❑ T e/Mf t <br /> i z <br /> PKG. TREATMENT PLT. ❑ T <br /> Method of Disposal <br /> Distance to nearest:— 4 Well Foundation Property Line <br /> LEACHING LINE ❑ No. R Length of` i Total length'/ <br /> .size A <br /> _ --- <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line~� <br /> SEEPAGE PITS I I Depth I Size Number <br /> SUMPS D Distance to nearest: i Well Foundation Property Line <br /> DISPOSAL PONDS 171 ?I� p <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#I <br /> "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ p y an y 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 o alifornia." u <br /> The al ca t call for all required inspections. Complete drawing on reverse side. <br /> Signed ul Title: Date: ��o <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Ins n fa Date <br /> Additional Comments: 170 <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 /> INFO AMOUNT�bUE AMOUNT REMIT-TED CK 0RECEIVED BY <br /> C SH ATE PERMI7'fy0. <br /> n <br /> ♦ EH1a 3-241ftEV.r/H5r [�II�, b Q � 91- 1 <br /> EH -28 J IIp VY .—fly a <br />