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APPLICATION FOR PERMIT <br /> � - SAN JOAQUlN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> See 0040-fl- 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. TMs 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 /> Jab Address t :3 .3a 7[ City 5_rzxyim� Size 4 `p <br /> PM <br /> Owner's Name P?4.S 19v ir'fYU D , Address Phone r� _ <br /> Contractor's Name _cam Ro=R, License No. Phone rn *� <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 ❑ Tracy Type of Casing Specifications I �� <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout L ) <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P.. State Work Done N <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material IBelow 601 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION A' DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence XCommercial_ Others" <br /> Number of living units: Number of bedrooms <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. ❑ 9 Method of Disposal <br /> Distance to nearest: Well Foundation 10 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 9 Depth t Size Number' " <br /> SUMPS - ❑ Distance to nearest: Well FoundationProperty 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. <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."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performaLftheork for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant m t call for all required ' tion rawing on reverse side. <br /> Signed t `Tale: Date: q <br /> OR DEPARTI4F�SE QNLY0 0" <br /> Application Accepted by ! C,,w) r Date Area <br /> Pit or Grout Inspection by Date final Inspection by Date <br /> Additional Comments: <br /> g1k466-6781 ❑ L 369- ❑ Manteca 823-7104 ❑ Tracy $3556365 cant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 <br /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY CK DATE PERMIT NO." J <br /> +EH 13-24(REV.10/83) <br /> EH t428 <br />