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APPLICATION.:FOR PERMIT <br /> SAN JOAO.UIN;LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES.1 YEAR FROM DATE ISSUED <br /> ..,(Complete in Triplicate) . 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.This application is <br /> ,made in compliance with'San'Joequin County Ordinance No.I549 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District:toih;-i frrL, ti, }.,. ,4'. +fit+; It" {{.r, <br /> �Y yC.. 4Dr : M . 7r G Y. <br /> Job Address 3 .5� r ;�^�` "" Ci _,Lot Size PM <br /> Owner's Name Phone <br /> Contractor's Name License Na. .1 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 ❑ Tracy Type of Casing Specifications <br /> ❑ Public. ❑ Other ❑ Delta 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. -3/4i State Work Done <br /> Well Destruction ❑ Well Diameter Sealing venal (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 ❑ IType/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 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. 141 <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 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 must I r all required in pections. Complete drawing on revers ide. <br /> Signed XTitle: ��.�� _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> --i�' 0-7 <br /> Application Accepted by L' Date y Area <br /> Pu or Grout inspection by Date Final Inspection by Dates � <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3511 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2049, Stk., CA 95201 <br /> ICK NFO AMOUNT DUE ' AMOUNT REMITTED CASH AMOUNT BY DATE PERMIT'NO. <br /> 0C <br /> }� EEH 4-28 'H 13-24 IREV.161831 . ��a V �+ <br /> Q <br /> 1 s �•'S= <br />