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^� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> l Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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. 1 <br /> Job Address S �� ! f City• A_/t/ Lot Size PM <br /> Owner's Name `'y �" dress �( ��/ �f Phone <br /> Contractor ] Address 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 /> 11 Public F1 Other � la Delta Depth of Grout Seal Type of Grout <br /> I'I Irrigation ---Approx. Depth i I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work•Don.e <br /> Well Destruction ❑ Well Diameter Sealing Material I op 50'I <br /> rt, I <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1,1 111--iAIR/ADDITION l I DESTRUCTION NZINo septic system permitted if public sewer is <br /> vailable 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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size , <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line «r <br /> SEEPAGE PITS i I Depth Size _ Number <br /> SUMPS LI Distance to nearest . Well"" - -Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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, 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 applican UP, ca f piall required i ctio Complete drawing on revside, / <br /> Signed X r Title: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r Area ` <br /> Pit or Grout Inspection by D,r;o Final Inspection by Date Z <br /> Additional Comments: �l C 4 Ya <br /> ❑ Stk 466-6781 ❑ Lodi 360-3621 ❑ Manteca 823-7104 ❑ Tracy 835'-&3EW �� TS <br /> po <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. oxl Stk., CA 9520 dFEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. �{ <br /> +.EH 13-24IREV.ti K5) & 0 3 ,57 0 0 2 <br /> EH 1128 � 00 ✓ <br /> J.D 1 <br />