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F APPLICATION FOR PERMIT <br /> `'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ;.�.�,V., (Complete in Triplicate) ' <br /> d/or instal!the work herein described:This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct an <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump-and the Rules and Regulafionof the San Joaquin <br /> Local Health District.) . <br /> ! Lot-Size PM <br /> City <br /> _ <br /> Job Address <br /> Phone <br /> Owner's Name UCA'� Address <br /> License No. Phone <br /> Contractor's Name ,rte <br /> �— <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> �— PUMP INSTALLATION SYSTEM REPAIR C1 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK, <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> )(Domestic/Private C1 Gravel Pack} ❑ Tracy Type of Casing S } <br /> "I Cl Delta Depth of Grout Seal Type of Grout f <br /> t ❑ Public El Other A <br /> ❑ Irrigation ---Approx,`Dep ❑ Eastern rS rf ce Seal Installed-by <br /> i H.P._ II�! State Work Done S <br /> Repair Work Done Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50'11 f <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION d DESTRUCTION ❑ (No <br /> Ave <br /> P�within 200 permitted if public sewer is <br /> Installation will serve: Residence} Commercial— Other 4 <br /> is <br /> Number of living units: " Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet:' No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg+ Capacity Method of Disposal <br /> PKG. TREATMENT PLT.❑ Property Line <br /> Distance to nearest: Wel! Foundation P r'ty <br /> G <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Pro Line r <br /> FILTER BED ❑ Distance:to nearest: Well Foundation Property A- <br /> ��� _--- <br /> SEEPAGE PITS ❑ Depth Size Number <br /> Property Line <br /> SUMPS ❑ . Distance� nearest: WellFoundation <br /> DISPOSAL PONDS Ll <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 /> Houle owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner n to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> I 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." r ' <br /> The applicant mus a r all required ' spections. Complete drawing on rev rse side. " <br /> Title: Date: t <br /> Signed <br /> FOR PARTMENT USE ONLY G O = 4 <br /> Date /l �e Area <br /> Application Accepted by k2 `4�r Date <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <br /> Additional Comments: racy r mgr, <br /> ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8 -71Q4 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 . Hazelton Ave., P.O. Box 2009, Stk.. CA 95201 <br /> CK RECEIVED BY DATE aPIRMITC . <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> +EH 13.24 IREV.10/831 <br /> EH 1428 _ F r <br />