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C APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �� <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 y e <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY <br /> (Complete in Triplicate) � p <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/o install the wor# }� <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the FIN! r � hts cation is <br /> Local Health District. a Joaquin <br /> � " 1301 <br /> Job Address z/ City of Size PM <br /> Owner's Name ! dt7&s p <br /> lPhone <br /> Contractor Address �T <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> '" PUMP INSTALLATION❑ SYSTEM REPAIR O <br /> "' __. OTHER Q �S-!1!W'�� <br /> DISTANCE TO NEAREST: SEPTIC TAMC SEWER LINES = <br /> DISPOSAL FLD.. PROP I:lNE - '-- - <br /> FOUNDATION AGRICULTURE WELL OTHER WELL — PITS/ UMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Specifications <br /> 1-1 Public <br /> I-) Other F Delta depth of Grout Seal <br /> i I Irrigation q <br /> DType of Grout <br /> pprox. <br /> Depth ( I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pumpr H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter: Sealing Material (top 501 i <br /> Depth Filler Material Ieelaw 50'} O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial_ Other available within 200 feet.} <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg I Capacit <br /> Y No. Compartments <br /> PKG. TREATMENT PLT. ❑ � <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> i Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to�nearest: Well Foundation <br /> � Property Line <br />­...z—SEEPAGE.P_I_T.S --- ;.., a.I.4Depth Size Number <br /> SUMPS <br /> ❑ Distance to Barest: Well FoundationPrpperty Lie <br /> DISPOSAL PONDS Eli - b^+ <br /> hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and r <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 applicant must call for all repair d inspections. Complete drawing on r rse side. <br /> Signed X <br /> Title: Data: <br /> �OR DEPARTMENT USE ONLY _ <br /> Application Accepted by °` <br /> Date �}7 Area <br /> Pit or Grout Inspection by Data Final Inspection b <br /> 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 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> _ I <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO p] CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH1 -24fREV.tiKs1 50 /t _ — <br /> EN 1428 �! �t� ► Ct5 O ( �� f"I <br />