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APPLICATION FOR PERMIT <br /> 0. 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 Qunty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. RX,)%3LoL 4 <br /> �./ <br /> Job Address Cf Al �� 1, 4 -«• City V1 a Lot Size � PM C <br /> Owner's Name ZXJ d /2 Address Phone <br /> Contractor's Name �a License No. Phone - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL�REPLACEMENT LJ 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 /> ll ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O <br /> l ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P,j State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 t /� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 11 available within 200 feet.) <br />` Installation will serve: Residence _.1._ Commercial_ Other <br /> Number of living units: Number of bedrooms IT <br /> Character of soil to a depth of 3 feet: D ' - Water table depth <br /> SEPTIC TANK D' Type/Mfg Capacity�No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well Foundation C26 Property Line ` �6U� <br /> LEACHING LINE I No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation�. � Property Line C-17--t <br /> SEEPAGE PITS Depth Number <br /> SUMPS ❑ Distance to nearest: Well yd Foundation 1 tl Property Linek,4-v�c�r'9 <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, 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 Californian <br />+� The applicant must dell- r all required inspections. Complete drawing on-reverse side. <br /> I Signed X Title: Date: <br /> fff FOR DEPARTMENT USE ONLY <br /> Application Accepted by K. Date z� Area c t <br /> Pit or Grout Inspection by J0 Date UP/ 1 Final Inspection by ate"q, <br /> q, <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT`NO. <br /> + EH 13-24IREV.10/83) <br /> EH 14-26 01 �l <br />