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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 456-6781 <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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. f <br /> Job Address Lot Size 00 i PM <br /> I LA3 <br /> k �� J.' pp <br /> Owner's Name �,1� �, Address t� r��C ` Phone I <br /> Contrac - LU Address . 3� �1�� License fVo���ZZ(e- Phonla IDS <br /> TYPE OF`WELL/PUMP: j f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST 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 G <br /> D Industrial D:Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F] Public ❑ Other. f__1 Delta Depth of Grout Seal Type of Grout__ <br /> I I Irrigation _..Approx. Depth l I 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 /> �--•- Filler Material (Below 50') <br /> TYRE, SFPTI ORK: FW INST_ALLATIO REPAY 1filADDITIO DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation-willserve:*-Resdce: Commercial t er_ <br /> Number of living units: Number bedrooms ` <br /> -�•. 5 r <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK T r <br /> ype/Mfg Capacity�.Q�..,___ �No:':Compartments <br /> PKG. TREATMENT PLT. c< ' f f Method of Disppsal' <br /> Distance to nearest. Well 50 Foundation � Property Liner <br /> LEACHING LINE No. & Length of lines Total length/size, <br /> FILTER BED ❑ Distance to nearest: Well Foundation��_ Property Line <br /> SEEPAGE PITS 11 Depth Size _2 _ Number r <br /> ADOSUMPS 'Distance to nearest: Well Foundation L� Property`Lin_e <br /> DISPOSAL PONDS <br /> X <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 /> 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 applican st cal o all paired inspections. Complete drawing on reverse si <br /> Signed X Title: �,}4 Date: <br /> _ FOR DEPARTMENT USE ONLY <br /> (7 <br /> i Application Acceptedby�`� --�� ri Date Area ` <br /> Pit or Grout Inspection by Date Final Inspection bye-ice Date--��c7 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 <br /> e <br /> FEE <br /> INFO DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMiT'NO. <br /> INFO (CASH <br /> + EH 1 .21(REV.I/a 51 7�1, ���/00 1•�S'tk 1� \ ' 1� • _I�- i t �� � <br /> EH 1I4-26 <br />