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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephohe (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> x ;'< (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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ' <br /> ap ro J QT' rl c <br /> Job Address <br /> Gn City Lot Size PM <br /> Owner's Name + <br /> l[ {p f Address Phone <br /> Contr '1 � <br /> iNaft ? Phone' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK -t fto - SEWER LINES DISPOSAL FLO. PROP. LINE ,r <br /> d FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ 1 d <br /> ustrial lEIOpen Bottom E5 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �!V f <br /> H'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> n Public ❑ Other F1 Delta Depth of GroutSealType of Grout <br /> I Irrigation —.-Approx. Depth I I Eastern YSurface Seal installed by - <br /> Repair Work Done ❑ Type of Pump-.4&W-e'-�Q- H.P. �/ - State Work Done r <br /> Well Destruction ❑ Weil Diameter Sealing Material Itop 501 <br /> Depth Filler Material iBelow'50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR./ADDITION { I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: R_es_idence ..-- 'Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: T Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal _ <br /> a <br /> i Distance to nearest: Well f=oundation Property Line <br /> \ ' <br /> LEACHING LINE ❑ 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 <br /> I 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 Locel Health Di_§trict:,­: <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 ust call for all reed inspections. Complete drawing on reverse side. <br /> ,,_ � <br /> Signed �is.�� Title: """` �_ Date: <br /> FOR DEPARTMENT USE ONLY s <br /> r Application Accepted by- _ - Date Area " <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: w <br /> ❑ Stk -466-6781-`--0--Lodi- 369-3621--.— •0 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK � 'RECEIIIEO BY DATE PERMIT'NO. k <br /> INFO CASH rr/�► j� ti _ <br /> +.EH 13.21(REV.t i h 5) <br /> EH 14-26 1111 """'yyY t <br />