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APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE„ STOCKTON, CA p,,, ` <br /> Telephone (209) 466-6781 !�U <br /> PERMIT EXPIRES T 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> L ld ` ,.. <br /> Job Address City /.f7 !A- of Size )9 A PM / <br /> rr6 <br /> Owner's Name H`& �/� (�l�9'�/�J Address '�` Phone <br /> Contractor Address. - License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ 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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 71 Public I.1 Other F Delta Depth of Grout Seal Type of Grout <br /> —.— <br /> i I Irrigation" Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. x State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below•50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i.l DESTRUCTIO INo septic system permitted if public sewer is <br /> i 11 ilable within 200 feet.) <br /> Installation will serve: Residence b Commercial— Other I <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ - Method of Disposal � <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size r " <br /> I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property"Line <br /> SEEPAGE PITS I 1 Depth Size Number i <br /> a <br /> SUMPS C 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> t 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 td.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." 11 <br /> The applicant u call for all required i ions. Complete drawing on reverse side. <br /> Signed Xt Title: Date: <br /> r R DE&ARTIMENT USE ONLY <br /> Application Accepted by Y`1 S� �, Pate --' { 1 J 1 1W <br /> Pit or Grout Inspection by Date Final Inspection b Dat 's 21 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> FEE <br /> INFO OUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMiT•NO. I <br /> S.� i <br /> +.EM 13-24 IREV.f/x sr —..�� <br /> EH 1128 a tJ 47 <br />