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APPLICATION FOR PERMIT <br /> SAN JOAQUIN 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) <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 age or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, 0 G AJ e— r <br /> Job Addressy City Lot Size PM <br /> Owner's Name pahaAddress Phone <br /> Contractor / _ 61.w Address $ AO 2� License No. 99l0 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 ITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO ATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia a Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F Public ❑ Other ❑ Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Dep l 1 Eastern Surface Seal Installed by w <br /> Repair Work pone ❑ Type of Pu WP. State Work Done <br /> Well Destruction ❑ Well Dia eter _ 5eafing Material )top 50'I <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO INo septic system permitted if pub <br /> available within 200 feet. <br /> Other <br /> lic sewer is <br /> ► <br /> Installation will serve: Residence_ Commercial_ j <br /> Number of living units: Number of bedrooms <br /> I <br /> Character of soil to a depth of 3 feet: i Water-table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line 7 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 0 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 taws, 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 /> The applicant t call for all required -nspe 'ons. Complete drawing on reverse side. <br /> Signed X Title: / <br /> Date: Z mm <br /> FOiR DEPARTMENT USE ONLY r <br /> Appliction Accepted by Da4e 4 U Area <br /> Pit or Grout Inspectiby Date Final Inspection by Date f! 0 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> ASHRECEIVED BY DATE PERMIT NO. <br /> +.EH 13-24 IAEV.t i H 51 �� <br /> EH 1429 f <br />