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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " <br /> (Complete in Triplicate) t <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. f <br /> Job Address ��l /u f + � �1 AG� City Lot Size PM <br /> Owner's Name -11 <br /> / 154 Address Phone ` <br /> Contractor Address CLicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL C,� 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 Z <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 bGravel Pack ❑ Tracy Type of Casing Specifications. <br /> ❑ Public ❑ OtFer ❑ Delta Depth of Grout Seal Tzpe of Grout Z <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump :!5:19& H.P. State Work Done_ e <br /> Well Destruction ❑ Well Diameter Sealing Material atop 501 t <br /> Depth Filler Material iBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic.system permitted it public sewer is <br /> available_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 depths -. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 17 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line, 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size may. <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> y <br /> SEEPAGE PITS ❑. Depth Size Numbers . <br /> SUMPS 17 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t ` <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 Locat.Health District. ' ' r . <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 applica=ti `requ�e � ctions. Complete drawing on revs Ids. 1 <br /> Signed X Title: � Date: <br /> { OR PARTMENT USE ONLY <br /> Application Accepted by 1f`� Date 3� 3 -> Area <br /> Pit o rou nspection by ' to Final Inspection by Date V " <br /> 0 A <br /> 1 ` <br /> Additional Comments: ` <br /> ElStk 466-6781 ElLodi 369-3621 ❑ Manteca 823-7 ❑ Tracy 835-6380 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.. CA 95201 <br /> FEEOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 13-24(REV.lies) b� ,�� G - G7/ <br /> EH 14-28 <br /> C� � <br />