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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I 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 Rules and Regulations of the San Joaquin <br /> Local Health District. l <br /> Job Address �� Q City " Lot Size PM <br /> C <br /> � <br /> Owner's Name � f� t`? Address <br /> r �a <br /> ,S Ifeeif y`�• /C� �Q icense No. JOU`._u' r Phone <br /> Contractor Address <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS <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 /> E <br /> INTENDED USE TYPE OF WELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F1 Industrial ❑ Open Bottom CJ Manteca Dia. of Well Excavation Dia. f Well Casing G <br /> ❑ Domestic/Private ❑ Gravel Pack a `El Tracy Type of Casing Specifications {� <br /> (-I Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout �} <br /> I I I Irrigation —.Approx. Depth", l I Eastern Surface Seal installed by <br /> Repair Work Done "L7 Type of Pump V H.P. State Work Done <br /> Well Destruction * Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') - '\ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION I 1 Mo septic system permitted if public sewer,is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br />'k Number of-living unit - Number of bedrooms <br /> i I Character of soil to aAepth of 3:feet:, Water table depth <br /> SEPTIC TANK ❑ Type/Mfg's Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �`` Method of Disposal <br /> Distance to nearest: IN.-Well Foundation Property Line <br /> Total len th/size <br /> LEACHING LINE I-] No. & Length of-lines g <br /> iFILTER BED LJ Distance to nearest: ; -Well ` ~ Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl 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. r -, <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 cert fi y 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 Calif <br /> The applicant, u call for all require ctions. pieta drawing reverse side. n g <br /> Signed X <br /> Date: <br /> LJ L/ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date A a U <br /> Pit or Grout Inspection by Date Final Inspection by Date pS <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 AMOUNT DUE AMOUNT REMITTED CAS ECEIVED BY D E PERMIT'NO. <br /> INFO / T f/xJ, <br /> +.EH13-241REV.riKsi 0 ) r f4gz <br /> EH 14.26 LLL!!L//""" V <br />