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0 ' APPLICATION FOR PERMIT <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ` I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) w <br /> application is <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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. IW-for well/pump and the Rules and Regulations of the San Joaquin <br /> .Local Health District. c ;� � Lot Size AC PM <br /> e �f <br /> � <br /> - , City L � <br /> Job Address <br /> �, < Address <br /> Owner's.Name <br /> Phone <br /> 1 <br /> License No. Phone <br /> Contractor's!Name DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL t1 WELL REPLACEMENT Q <br /> PUMP,IiNSTALLATION D x 1"+ 'SYSTEM REPAIR ❑:, OTHER ❑ <br /> DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. r PROP. LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS"tzDia. of Well Casing <br /> ❑ Industrial 1 ❑ Open Bottom ❑ Manteca v Dia. of Well Excavation. 4 <br /> 4 ;(s a Type of Casing t Specifications <br /> ❑ <br /> Domestic/Private. ❑ Gravel Pack ❑ Tracy 5_ t �y,f* 3 } T of Grout <br /> ❑ public ❑ Other ❑ Delta Depth of Grout Seali Type <br /> rox. Depth ❑ Eastern.— ----Surface-Seal Installed by <br /> ❑ Irrigation App . <br /> H P State Work Done 4,N""0'1 <br /> t Repair Work Done ° D Type of Pump # v' <br /> Well Destruction ED Well Diameter Sealing Material Stop 50'} <br /> i <br /> DeptI41 Filler Material IBel0w_50') - - ! <br /> 1 ORK: NEW INSTALLAREPAIR/ADDITION ❑ DESTRUCTION Q-(Nova septic system permitted if public sewer is <br /> TYPE OF SEIC WTION I <br /> � ..; . available within 2{10 feet.! <br /> t ; <br /> Installation will serve: Residence Commercial_ Other <br /> � t <br />?. Number of living units: ' Number of bedrooms ( -Water table depth20 <br /> f,. Character of soil to a depth of 3 feet ` Capacity O _ No. Compartments <br /> SEPTIC TANK i TP- Typeimfg A_ - �'" ` Method of.Disposal <br /> ` PKG. TREATMENT PLT. ❑' '; C7 r Property Line <br /> U Foundation r <br /> 1 Distance to nearest: . Well�" 1 j <br /> c `Totalfl'ength/size <br /> I LEACHING LINE No. & Length of lines :. _. <br /> FILTER SED ❑ Distance to nearest: WeII Foundation � - Property L. <br /> t <br /> Size Z r i Number.- <br /> s SEEPAGE PITS Depth <br /> k SUMPS <br /> 11 Distance to nearest: Well ��-Il Foundation �- Property Line <br /> {{ r DISPOSAL PONDS. ❑ <br /> T. 1 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 /> k. rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent'ssignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I signature <br /> shall not <br /> ' ring or sub <br /> employ any person in such manher as to become subject to workman's compensation laws of California."Contracts Contractor's <br /> subject to workman'-scompensa- <br /> certifies the following:"I certify that in the performance of the work f r which this permit is issued,I shall employ pe <br /> tion laws of California." <br /> t <br /> The applicant,must call for all required inspections. Complete drawing on reverse side. <br /> Date: <br /> Signed <br /> OR DEPARTMENT USE ONLY <br /> . Date Area <br /> €Application Accepted by , -;i i,` _ Q �f D t <br /> / r <br /> Date Final Inspection by �!�✓ e� <br /> 1: it�r Grout Inspection by� <br /> Additional Comments: j <br /> -1 Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 f <br /> rilicant- Return all cop, to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> " K RECEIVED BY DATE PERMIT°NO. <br /> FEE', AMOUNT DUE AMOUNT REMITTED Cgsµ <br /> INFO O <br />