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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 j <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 J G ` ' City C-�Size PM <br /> tl. /. Address .�y Phone <br /> Owner's Name _ a <br /> Contractor's Name � o.ense N , <br /> ��2- 7 CEJ % - Phone <br /> TYPE OF WELL/PUMP:,i—; NEW WELL ❑ ^SWELL REPLACEMENT ❑ DESTRUCTION ❑ - / ; <br /> PUMP INSTALLATION ❑' J' SYSTEM REPAIR ❑ OTHER� /tOfrA"P& <br /> DISTANCE-Te.1VEARES 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 Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T pe of Grout <br /> ❑ Irrigation ---Approx. Depth o Eastern Surface Seal Installed by <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 IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑) DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 4 " available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other ,r th <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 fff <br /> a <br /> PKG. TREATMENT PLT. Method of Disposal <br /> F-1 � � � P PP <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 ❑ Depth_ Size Number Y <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r <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 /> I Home owner or licensed 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.)n such man er as to become subject to workman's pensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fol( Ing:"I certify hat in the performance of the wor r ich t is permit i ued,I shall employ persons subject to workman's compensa- <br /> tion laws of lifornia." <br /> The applic t must call all quirad i t�ectiooa. averse / �j <br /> Signed <br /> Date: /�` /< <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Mv, Date �"' � Area <br /> Pit or Grout Inspection b Date Final Inspection by Date <br /> Additional Comments: — <br /> ❑ Stk 4W6781 ❑ 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 REMITTED CK RECEIVED BY DATE PERMIT"N0. <br /> { INFO CASH <br /> +EH 13"24 4REV.10/831 J- <br /> EH 1426 a Q 4� <br />