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APPLICATION FOR PERMIT <br /> I ? SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r 1601 E. HAZELTON AVE., STOCKTON, CA <br /> r <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 C unty Ordinance No.549 or sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ZQ City -AlLot Size PM <br /> { L <br /> Owner's Name _W7-Z L,� /yI/�N 4q�l t (✓Phne <br /> 6 �2 <br /> Contractor Address License No. Phone 3� <br /> „ TYPE OF WELL/PUMP: ,.- NEW WELL ❑,. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION)d�PA/%rfiAYSTEM 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 <br /> F1Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done El Type of Pump �a H.P. State Work Done <br /> Well Destruction ❑ Well Diameter { Sealing Material (top 50') ( 1 >il <br /> Depth ' Filler Material (Below 50') - \� <br /> TYPE OF SEPTIC WORK:-NEW INSTALLATION ['I REPAIR/ADDITION lJ DESTRUCTION l I (No septic system permitted if public sewer is <br /> I available within 200 feet.I <br /> Installation will serve: Residence_�' Commercial_ Other <br /> Number of living units: Number of bedrooms 1 <br /> Character of soil to a depth of 3 feet: Water table depth I <br /> SEPTIC TANK ' ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: i Well ...Foundation l Property.Line <br /> LEACHING LINE ❑ No. & Length'of lines - Total length/size I <br /> FILTER BED ❑ Distance to nearest: Well Foundations r '.k 1 3 <br /> Property Line 4 <br /> _ <br /> ' SEEPAGE PITS I ) Depth '� � � Size _ Number �~ 4 <br /> SUMPS ❑ Distance to nearest: Well ,Foundations Property Line+L <br /> LL— <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.e6unfy ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Districte," "'_' f = 1._ <br /> Home owner or licensed agent's signature certifies the.followin ✓ <br /> 9 9 g: "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. Cbntiactor'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-pe�sons �subject to workman's compensa- <br /> tion laws of California." h <br /> _The applicant all.re pections. Complete-drawing on-re rs ide. _ - <br /> - <br /> Signed X Title: Date: <br /> t " 1 '"'t '�'A <br /> __- <br /> FOR*DEPARTMENT,USE'ONLY, <br /> Application Accepted by, — - --DateV- <br /> .,. .�. Area - <br /> I' <br /> Pit or Grout Inspection by Date Final Inspection by Date � <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ` ❑ Manteca 823-7104 C: 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 /> y. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, i <br /> +-EH13-21IRfV.1iy5Y „�4 <br /> EH UI-28 <br />