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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, HAZE, AVE., STOCKTON, CA N1D <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to thJ San Joaquin Local Health District for a pemit to construct and/or install the work herein described. This application is <br /> made in compliance with San Jo quin County Ordinance No. 549 for sewage�r No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �- °'—'/ City4AA1Lot Size PM <br /> Owner's Name rt�P I� Ak�yddress `�aI?�1f' as - Phone <br /> �I <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 Om=:� <br /> FOLD.- ROP. LINE <br /> FOUNDATION AGRICULTURE WELL LL PITS/SUMPS <br /> INTENDED USE TYPfE OF WELL PROBLEM AREA CONST N SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing,. <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tr > Type of Casing Specifications., r <br /> h1 Public ❑ Otfher Delta Depth of Grout Seal Type of Grout—.-- <br /> it <br /> rout i <br /> I I Irrigation �..Ap epth l 1 Eastern Surface Seal Installed hyo <br /> Repair Work Done ❑ e_ of Pump k H.P. State Work Done <br /> Well Destructi ❑ Well Diameter Sealing Material (top 501 € <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEWINSTALLATION l 1 REPAIRIADDITION l 1 DESTRUCTIONII] Mo septic system permitted if public sewer is <br /> available within 200 feet.) r <br /> installation will serve: Residence_ Commercial_ Other <br /> Number of living units: i Number of bedrooms <br /> Character of soil to a depth of,3 feet: = Water table depth <br /> .� a I <br /> SEPTIC TANK , ❑ Ty a/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 4 r ' Method of Disposal <br /> t <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE ❑ No. & Length_of lines. Total length/size <br /> q, <br /> FILTER BED ❑ Distance to nearest: well Foundation Property Line <br /> SEEPAGE PITS l I Depth Sized Number. r <br /> SUMPS Ll 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 SarJoaquin Local Health District. ` <br /> Home owner or licensed agent's i'ignature 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 I or which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." III <br /> The applicant mus all far ail r quired i sped n Com to'drawing on reverse side. <br /> Title: <br /> Vfill 1�1 L {� <br /> Signed X _ Date: � <br /> I <br /> I FOR DEPARTMENT USE ONLY �] <br /> Application Accepted by k Date S '� 1 Area �! <br /> Pit or Grout Inspection by I� Date Final Inspection by ' Date_ --.� <br /> I u _ <br /> Additional Comments: I f a <br /> ❑ Stk 466-6781 ❑ Lodi.I;369-3621 ❑ Manteca 823- ❑ Tracy 6385 <br /> Applicant - Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> J <br /> FEE AMOU14T DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*IVO. <br /> INFO CASH <br /> EH+ 13 4 JREV.1/8 51 <br /> EH 2 <br /> � i U(] "_ �-✓ ���� / S( / -'�� <br />