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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE. 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 County Ordinance No.549 for sewage or No. 1851 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.. <br /> 37 I <br /> Job Address C> ���[1 p } City Lot Size PM <br /> Owner's Name 4" 1nf. 0014D4)Address �® _.. Phone "3:71 <br /> Contractor C Address 4f IJ �pense No.37 Phone —33 <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 Dia. of Well Casing <br /> Domestic/Private ❑ 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. rtjZ State Wor Done <br /> Well Destruction ❑ Well Diameter 14+ Sealing Material (top 501 f>7 <br /> Depth ° Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E) REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.l <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 depth k (� <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 <br /> I. <br /> FILTER BED - , ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 /> 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."Contra�tior'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 t&workman's compensa- <br /> tion laws of California." <br /> The applican m st c I for all required i spections. Complete drawing on rreverse side. <br /> � <br /> '�'Signed Title: � ",p f" Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Ay Area !f <br /> Pit or Grout Inspection by ate Final Inspection by Date <br /> f <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> / <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 CV /R}E/C�EIVED By DATE PERMIT"NO. <br /> 00 <br /> + IREV.1/051 <br /> EH EH 14-24 5- ��� 7 \ '�/`� V "VLOf <br />