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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 4 <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin t <br /> Local Health District. / �/�' <br /> QiM/ City R�� Lot Size PM <br /> Job Address - / /�-� 7Y <br /> J <br /> Owner's Name <br /> `�~ 1 Address `� f7` CJ 49 C.G .� /�. Phone <br /> Address License No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL F7WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION 1­1SYSTEM REPAIR LJOTHER ❑ <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 /> 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other LlDelta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONN <br /> alvailseptiable wshtem permitted public sewer is <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 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT- ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br />' I <br /> SEEPAGE PITS 171Depth Size Number <br /> SUMPS ❑ 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. <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 /> c The applicant must call for all required inspections. Complete drawing on reversp siid <br /> X` e. �-L,._�� <br /> Signed Title: �b-0 Date: r <br /> J FOR DEPARTMENT USE ONLY C� (�'} <br /> Application Accepted by Date LArea y <br /> Pit or Grout inspectio to Final Inspection by Date <br /> Additional Comments: K� arm f <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy.. 8i5-63% <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE INFO PERMIT`NO. <br /> .:�j/�./�/, / <br /> + EH 13-24 IREV,t/e 51 5, _ <br /> EH W28 <br />