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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) 4571 `-r <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. n <br /> Job Address City O Size PM <br /> Owner's Name oar �� /l �� Address Phone <br /> Contractor Address icense No.3`� �'��d Phone <br /> TYPE OF,WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> $E PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST:.SEPTIC TANKSEWER 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 r <br /> } - <br /> 4 <br /> PCT Domestic lPrivate ❑ Gravel Pack LJ Tracy \\Type' of Casing Specifications <br /> M <br /> Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation e <br /> 9 --Approx. Depth l Eastern Surface Seal Installed by <br /> Repair Work Done Type of PumpH,P. ^� <br /> * State Work Done CJ <br /> Well Destruction ❑ Well Diameter 'Sealing Material ftop 50,I,' <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION I ] DESTRUCTION I I (No septic system permitted if public sewer is <br /> 4. available within 200 feet.) <br /> Installation wilhserve: ,Residence Commercial_ Others <br /> Number ofliving units! Number of bedrooms <br /> Character of soil to a depth of 3 feet:'R� ' Water table depth <br /> SEPTIC TANK ' ❑r,Type/Mfg � Capacity , No. Compartments <br /> PKG, TREATMENT PLT. ❑ " `" Method of Disposal <br /> < d Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER.-BED` ❑ Distance to nearest: Well Foundation Property Line I <br /> R - <br /> �% 1 <br /> i SEEPAGE PITS ,, I I Depth Sire_ 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 be done in accordance with San Joaquin county ordinances, state laws, and i <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 /> Thea Zhll,,�a.11,for all requi Inspect s. Com a drawing on r rse side. <br /> Signed X Title: <br /> Date: f <br /> jp FOR DEPARTMENT USE ONLY <br /> Applicati6n Accepted by _ Date V V Area ` <br /> Pit or Grout Inspection by Date Final Inspection by Date 7�l�1 � <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 i <br /> FEE AMOUNT DUE ACK <br /> INFO MOUNT REMITTED' CASH RECEIVED BY DATE PERMIT•NO. <br /> 77/+.EH 13-24 1REV.1/H 51 <br /> EH 14-29 VVV <br />