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� .,. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. I" <br /> &O <br /> Job Address A.! City L,ot Size PM I <br /> Owner's Nei �-�~ ddress V r' f r' `-� Phone ` <br /> Contract kXC1lI N;a.3! +U7 Addressr. d— License No 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 /> ❑1 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 (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:XA Number of bedrooms <br /> Character of soil to a depth of 3 feet: AWA& 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 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 ❑ F <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinancestate laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent,,,signature certifies the following: "I certify that in the performance of the work for which this permit issued, I shall not <br /> employ any person in su manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-caWcting.signature <br /> certifies the following: ' certify that in theperfor ce of the work for which this permit is issued,I shall employ persons subject to worhan's cl3mPensa- <br /> tion laws of Califo <br /> The appl call for all requir s cti s. vmp to drawin e. <br /> 77. <br /> Signed K Title ate <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C 14— Date L Area ` <br /> Pit or Grout Inspection by Date Final Ins tion b Da <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ LocW 369-3621 ❑ Wanteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant - Return all co as to, Environmental Health Pe /Services 1501 E. Hazelton Ave., P.O. Box Stk., CA 9152111 <br /> INFO FEE AMOUNT DUE AMOUNT RE ITTED CASH R <br /> E <br /> CE <br /> IVE8Y DATE PERMITT'N0- <br /> + EH 13-241REV.1/85) IS, 00 !�7 p ^J—g�p � /o�� <br /> EH 1428 <br />