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y APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> 1601 E. !-HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 APR 4 2 1"l <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUM„ <br /> (Complete in Triplicate) IRONMENTAL HEALTH <br /> PERMIT/SERVICES <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 / City of Size 6Lw-- PM <br /> Owner's Name D bl�j [� Address Phone <br /> Contractor-� Address 9d- icense No. 1-WPhone <br /> TYPE OF WELL/PUMP: EW WELL � WELL REPLACEMENT ❑ DESTRUCTION 1-1PUMP INSTA LATION A( SYSTEM REPAIR El 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 <br /> r❑ Industrial D'Open Bottom ❑ Manteca 'Dia. of Well Excavation — =Dia. of Well Casing <br /> F-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ <br /> I I Irrigation —.-Approx. Dept I I Easter Surface Seal !n tolled by <br /> Repair Work Done ❑ Type of Pump P. State Work Done <br /> Well Destruction El Well Diameter Sealing Material (top 50') <br /> Depth Filler Material IBelow 50'I -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1 1 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other J <br /> Number of living units: Number of bedrooms U 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal 1 <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 i I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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. �p <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, !shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m t ca11 for"all re wired inspections. Com plate drawing on reverse side. <br /> Signed X r Title: _._ Date: 7 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection b Date <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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT-NO. <br /> + EH 13-24(REV.siN5) <br /> EH 14-26 <br />