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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> F 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 sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> f Local Health District. j <br /> Job Address � ��/`7'1A /V& .,-..XV27 City-4,V �OiflLot Size PM <br /> Owner's Name _ r_ <br /> pU/ Z?1VN141eJ_ Address Phone ! <br /> a <br /> Contractor Address Q License No. phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTfON <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 /> ❑ <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t <br /> Fl Public 11 Other l l Delta Depth of Grout Seal Type of Grout �l <br /> I i Irrigation _-Approxi Depth I 1 Eastern Surface Sea] Installed by <br /> Repair Work Done ❑ Type of Pump " H.P. State Work Done ,L <br /> Well DestructionWell Diameter ��T Sealing Material (top 50') <br /> Depth ! Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is \\ <br /> available within 200 feet.) <br /> Installation will serve. Residence A 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— t <br /> No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line (� <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance t{o nearest: Well Foundation Property Line <br /> SEEPAGE PITS i 1 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 or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 m all quire ions. Complete drawing on reverse ide. <br /> Signed X Title: i9 ; <br /> Date: /leg— 'I <br /> I <br /> �- - FO DEPARTMENT USE ONLY <br /> Application Accepted by "��'�-^-� � _ Date_ Lk—A—C?)(E6_ Area US <br /> Pit or Grout Inspection by ' Date Final Inspection by Date <br /> Llr <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lod 369-3621 ❑ Manteca 823-7104 ❑ 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 MITTEDCK 4 <br /> INFO CASH REC ED BY DATE PERMIT'NO. <br /> + EH 1 3'24 TREY.i i n 5) <br /> EH 14-26 <br />