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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 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.. i! <br /> ��, <br /> Job Address Ci Lot Size PM } <br /> Owner's Name r 7 d 1 I J lJ / t! <br /> Address Q .a 4t�-eE,a( Phone j <br /> -- i <br /> Contractor's Nam c!,Ya.-, C License No. Z <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r. <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 r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing J <br /> ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications ! t <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ill <br /> ❑ irrigation _ —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done C7 Type of Pump H.P. _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') Z <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— ther <br /> Number of living units: Number of b droom / 'f <br /> Character of soil to a depth of 3 feet: Water table depth S` <br /> ir <br /> SEPTIC.TANK ❑ Type/Mfg ,Capaciry No. Compartments <br /> PKG.-TREATMENT PLT. ❑ '' Method of Disposal <br /> Distance to nearest: Well Foundation Y Property Line <br /> LEACHING LINE. ❑ No. & Length.,of lines '' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line -� <br /> SEEPAGE PITS Depth 2 .size _ i�lumber <br /> SUMPS ❑ Distance to nearest: ✓Well!E o Foundation 0 Property Line <br /> DISPOSAL PONDS ❑ f r ; <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 workmahfs compensation laws of California.r Coritractor'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,rAust call for re ired inspections. Complete drawing on reverse side. <br /> 1 p t <br /> Signe — - iL w Title: 1�• f ..R.. . , . Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> CPR) <br /> r Grout Inspection by� Date <br /> Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca'M' 3-7104 ❑ 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 /> ' r � � i <br /> i <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK A RECEIVED BY DATE PERMIT"N0. <br /> i <br /> + EH 1324IREV.10!83) <br /> EK 1428 �S�p 0 J <br />