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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) <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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. Zf <br /> Job Address 4J / /� [� S City Lat Size / � A/� M <br /> Owner's Name h,' �'�l+ � Address -0. 00r g Phone <br /> Contractor 7f-A, / Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <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 (j� <br /> ❑ Domestic/Private D Gravel Pack C1 Tracy Type of Casing Specifications - 1 <br /> f"] Public CI Other ❑ 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 Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material lBelow 50 __ r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I 1 fNo septic system permitted if public sewer is V 1 <br /> available within 200 feet.) <br /> Ilation will serve: Residence— Commercial_ Other <br /> Numbe living units: Number of bedrooms <br /> Character of s a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. L] r;p al_. <br /> Distance to est: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length Total length/size <br /> FILTER BED ante to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L 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 he done in accordance with San Joao ui ounty 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 <br /> 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 applicant V <br /> ail required ns Ctions. Complete drawing on reverse side. <br /> Signe Title: _Y Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date5—, Area <br /> Pit or Grout Inspection Date Final Inspection by ° Date +� <br /> Additional Comments: <br /> ❑ Stk 466-6781 L] Lodi 369-3621 CI 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 /> CK INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE Sys //PPEEERRRMIT-IVO. <br /> + EH 13-24[REV. /n51 � . 00 <br /> /�7► ; �_/X <br /> EH 11-29 W K/ �} L(�(J/ ���TiLJ/ <br />