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I <br /> APPLICATION FOR PERMIT h <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E <br /> (Complete in Triplicate) <br /> i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1BG2 for well pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> �+ <br /> Joh Address r <br /> ,/�� � <G City Lot Size PM <br /> / - <br /> i <br /> Owner's Name • Address 11?5 O Phone <br /> Contractor's Name Z License No. 5,,2-,F z Z Phone <br /> TYPE OF WELL/PUMP: 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 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack E3 Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 00❑ Irrigation ---Approx. Depth El 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 50') ° 0 <br /> Depth Filler Material'lBelow <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is 71 <br /> available within 200 feet.) <br /> 1 <br /> s <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' Water table depth <br /> SEPTIC TANK ld' Type/Mfg L411 capacity___! 6,0 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well— —lamL Foundation =•Property-Line <br /> n <br /> LEACHING LINE No. & Length of lines d�> _ Total length/size _ <br /> FILTER BED ❑ Distance to nearest: Well 5-10 Foundation.1 12 Property Line..�— <br /> i SEEPAGE PITS ❑ Depth Size Number <br /> k SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> i 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. <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, l 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 applicant ust call for all requ�red inspections. Complete drawing on reverse side. <br /> Signed �1' Title: Date: <br /> FO ART T USE ONLY <br /> Application Accepted by <br /> Data 49 `1 " Area <br /> Pit or Grout Inspection by <br /> ate Final Inspection by Date <br /> Additional Comments: <br /> D 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 /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIV NO. <br /> INFO p� Q <br /> + EH 1324 IREV.10!83) S d o +���• 1 `��'"' �� <br />