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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA �p <br /> :Telephone (209) 466-67$1 <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. r <br /> Job Address 6 -301 0 _ e D-C 12 pityL { �p PM <br /> - /a 13 <br /> Owner's Name Address T M Phone Ait _7A-7 <br /> Contractor Address 14�7License No." 2323 Phone 4 - L- r4Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WEEL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Lq--- SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f' DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ I ustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation'' Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy ,Type of-Casing- Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal - Type of Grout <br /> ❑ Irrigation / ---Approx. Depth ❑ Ystern Surface Seal Installed by <br /> Repair Work Done Cil Type of Pumper H.P. a- State Work Done <br /> Well Destruction . - ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material.(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <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 t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth 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 cin 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 arson in su manner as to become subj workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies t following: "I ertify that in the rforma a of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion law of Calif nia." <br /> The ap licant mu t call' r all requ ed i o s. ormpletw rawing o r erse�i <br /> SignedAIN Title: "- Gate: <br /> ii.FOR DEPARTMENT t1SE ONLY / <br /> Application Accepted byC� Date s Gr �� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0-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 K RECEIVED BY DATE PERMIT NO. <br /> - • <br /> + EH13-24 IRfV.t/a 57 <br /> EH t4-2a <br />