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ti= f <br /> 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 0 EC.2 <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 v�oik\6&@ri,described.iThisFapplication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules IQ-tdn Joaquin <br /> Local Health District. <br /> Job Address ?> 5t City Lot Size PM <br /> Or <br /> Owner's Name. � �OC�C'/ -0.� Address V r✓ �a hone <br /> Atltlress� tISLicense PhoneContract � 97 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 9 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 b <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Packw ❑ Tracy Type of Casing Specifications <br /> f I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation ---Approx. Depth l I Eastern Surface Seal Installed by <br /> Rep2ir Work Done >f_ Type of Pump Al H.P. 6� State Work Done 0 <br /> Well Destruction ❑ Well Diameter Sealing Material atop 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: _Residence_ Commercial_ Other <br /> 4 <br /> Number.of-living-units: . Number ofbedrooms­ <br /> Character of soil to afdepth of 3 feet: Water table depth U} <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 0 No. & Length of lines_ Total length/size <br /> FILTER BED ❑ Distance to-nearest: Well Foundation.—_ - - Property.Line <br /> SEEPAGE PITS" I I Depth Size - Number W <br /> SUMPS ,: L] Distance to nearest: Well Foundation; Property Line W <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 Di§trict. t <br /> Home owner or licensed agent's signature certifies the following; "I certify that in'theL performance of the work for which this permit is issued, I shalt 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 appfican u all for all Req 're inspections. Complete drawing o reverse side. <br /> Signed4 v Title Date: J ' <br /> FO AR SE ONLY <br /> Application Accepted by Z 2Date r ¢ Area �–�'✓ <br /> Pit or Grout Inspection by Date Final Inspection,by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 fes' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> z <br /> CK <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY { DATE PERMIT NO. <br /> ,.CH 13-24 1REV,1/H bl 1 g <br /> EH 1428 <br />