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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEI_TON AVE.,'STOCKTON, CA <br /> : Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r <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.pand Athe Rules and Regulations of the San Joaquin <br /> Local Health District. .. }I° N <br /> -/-p G� � y ! om► <br /> Job Address S AaIl City Lot Size PM <br /> Owner's Name Address (!le► hone <br /> f . <br /> Contractor's Name ,- fne I' A� License No. al fr-M2 Rhone 3sJo <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION 91—, <br /> PUMP INSTALLATION ®f SYSTEM REPAIR ❑ �OTTH,ER El..�..,,..DISTANGE-TO-NEAREST._SEP-TIC TANK � d- <br /> .� 9 � SEWER_LINES ` - DISPOSALFLDA&-:t —PROP.-LINE• - • . - , <br /> FOUNDATION AGRICULTURE WELL OTHER WELL-.dA!L- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation N Dia. of Well Casing <br /> B'Domestic/Private CoIdravel Pack ❑ Tracy Type of Casing PVC Specifications 40 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation cp,40-9wrox. Depth ❑ Eastern Surface Seal Installed by <br /> El � <br /> Repair Work Done Type of Pump �6H.H•P• State Work Done <br /> Well Destruction ❑ Well Diameter 1 Sealing 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 i <br /> Number of living units: Number of bedrooms i <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 /> f <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 /> 1 <br /> SEEPAGE PITS ❑ Depth Size Number <br />`. SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 thafln.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 must II for all it mplete drawing on reverse side. <br /> i 2\ pe= Title: Date: <br /> Signed ; <br /> k <br /> o- FORVtPARTMENT USE ONLY <br /> - I,� } } .- -7-2- �e Area <br /> 'Applica' ccepted by w Date <br />} �4 Final Inspection-by <br /> !, Pit or ro Inspection by Date: spe" <br />' ,.`AdditionalComments: <br /> i <br /> ❑ Stk 4564781 ❑ Lodi 369-3621 ❑ Manteca "823-7104 ` C7 Tracy 835-63851 <br /> Applicant- Return all copies to: Environmental,Health-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1— <br /> G - FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> I' INFO <br /> +EH 1324[REV.101931 1 b CA a C � CZ+/ fsb- <br /> EH 14-26SZ r2 <br />