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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i`YEAR FROM-DATE ISSUED <br /> .. pL73 <br /> (Complete in Triplicate) i <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 R41es and Regulations of the San Joaquin <br /> Local Health District. - 1 <br /> Job Address J� y �/r �/ Q/(,�Il/� ` f t�City Lot Size *''S^ M <br /> Owner's Name flosiq Address _Y,+Al _ -- Phone — <br /> Contractor 7" A �✓ ddress License No."ion Phone <br /> TYPE OF WELL/PUMP: NEW VIELE71 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 I <br /> � 9 —Approx. Depth ❑ Eastern Surface Seal Installed by I <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') Jr <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INST <br /> OQ <br /> ALLATION REPAIR/ADDITION ❑ DESTRUCTEl (No septic system permitted if public sewer is d <br /> I available within 200 feet.) I,, <br /> Installation will serve: Residence_ Commercial_ Other W <br /> Number of living units: 1� N�um�be f�bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Yt /"� <br /> Capacity._12 00 No. Compartments �} r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well 2.0"( Foundation Property Line_S1 �I <br /> LEACHING LINE. [ No. & Length of lines Taal length/size f <br /> FILTER BED ❑ Distance to nearest: Well oundation Property Line y <br /> SEEPAGE PITS Depth Size N mber ' <br /> SUMPS ❑ Distance to nearest: Well Foundation�. Property Line (j <br /> DISPOSAL PONDS ❑ g <br /> 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." 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 ust call for all uired ins ctions. Complete drawing on reverse side. t <br /> Signed - <br /> Title: Date: �� <br /> R DEPARTMENT USE ONLY t <br /> Application Accepted by Date '` �/ <br /> Area <br /> it or Grout Inspection byT�_� Date F al Inspection Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009,,Stk., CA 95201 f <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO RECEIVED SV DATE PERMIT`NO. <br /> � Com, <br /> +EN 1426(REV.t/e51 �� .�� /�' bJ% <br /> `� <br />