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APPLICATION FOR PERMIT a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 1- <br /> Telephone (209) 466-6781 .� <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) �� T <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.. w <br /> Job Address a}� 17 % ��� 14ye City S r' 14 Lot Size SiK"ic 8Z7 / PM <br /> Owner's Name � � Address 2 Xr 090" Phone <br /> Contractor Address JA —7 Tr CA o License No. Phone 3 <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 FLO. 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 Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications IS <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by M1 <br /> Repair Work Done ❑ I Type of Pump H.P. State Work Done �/ l <br /> Well Destruction ❑ Well Diameter Seating Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other�4 . /��q, �Jl <br /> Number of living units: Number of bedrooms A V 1 / <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. (7 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line r <br /> LEACHING LINE _❑ No. & Length of lines Total Length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation; Property tine <br /> w <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 mu call fora required ' spections. Complete drawing on reverse side. <br /> 6t__52 <br /> Signed Title: � ..� _ - – __� Date: <br /> F R DEPARTMENT USE ONLY 0,3 <br /> Application Accepted by oat e Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 2!:� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638,5 <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 RE REMITTED C H RECEIVED BY DATE PERMIT NO. <br /> + EHt324(REV.5/s 51 <br /> EH 14-26 <br />