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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 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 Addross � City Lot Size / <br /> • I PM <br /> �i�6S•Y8�7 <br /> Owner's Name Address <br /> 1. Phone <br /> Contractor Address <br /> License No. Phone <br /> TYPE OF WELL/PU P: NEW WELL ❑ WELL`REPLACEMENT ❑ DE TION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . <br /> DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom nteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy T Dia, of Well Casing <br /> Type of Casing Specifications,_ <br /> ('1 Public Cl { Cl Delta, Depth of Grout Seal; _ <br /> I I Irri ation ype of Grout <br /> g" _._Approx1 Ti Depth 'I I Eastern Surface Seal Installed by <br /> Repair War ne LJ Type of Pump �> H.P. State Work Done T <br /> Welt estruction ❑ Well Diameter Sealing Material (top 50') ^ <br /> Depth f Filler Material-!Below 50'1_, tVl <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial Other available within 200 feet.) <br /> Number of living units: Number of bedrooms K, <br /> Character of soil to a depth of 3 feet:I <br /> SEPTIC TANK ❑ TypelMfgt Water table depth <br /> Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ t-a ` <br /> }-" Method of Disposal <br /> Distance to nearest:,- Well Foundation Property Line " <br /> LEACHING LINE ❑ No. & Length of lines' , <br /> Total length/size <br /> FILTER BED <br /> ❑ Distance to nearest:, Well <br /> Foundation <br /> Property Line I <br /> SEEPAGE PITS' 11 Depth 1 Size r <br /> Number <br /> SUMPS <br /> E1 Distance to nearest: Well Foundation._ - � ' <br /> DISPOSAL PONDS Cl - Property Line <br /> t 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 ar licensed agent's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shalt 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 California." <br /> The applic mus alt for all requir d "nspections. Complete drawing on reverse side. <br /> Signed X , <br /> Title: <br /> .� Date: [o <br /> FOR DEPARTMENT USE ONLY <br /> N <br /> Application Accepted by <br /> Date ",.Area <br /> Pit or Grout Inspection by Dateri <br /> al In ction by D��._, : OO <br /> Additional Comments: � �C.✓V � r � p�� y <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 L/ <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNTDUE AMOUNT REMITTED CK <br /> +.EH t3-241RE1r. <br /> INFO S <br /> 51 FH RECEIVED BY DATE PERMITNO. <br /> 7/H <br /> EH 14-29jA <br /> • �+ <br />