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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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, <br /> Job Address / <br /> 7`s��- 7 v� City Lot Size PM <br /> Owner's Name ll Address .S C` f"7 r/ S Phone .7 <br /> Contractor il e,/r Address License No. Phone <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. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material-(fop 50')- - <br /> Depth Filler Material (Below 501 6 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other W <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> G <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size o <br /> FILTER BED ❑ Distance to nearest: Wellin'Z Foundation <br /> 4 Property Line L-2 <br /> SEEPAGE PITS ❑ Depth Size r Number �- <br /> SUMPS ❑ Distance to nearest: Well Foundation f .Property Line <br /> DISPOSAL PONDS ❑ r <br /> I hereby certify that I have prepared this application-and that the Wolk will be done in accordance wiih 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 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 mu II for all requ. d inspec' ns. C mplete drawing on reverse side. <br /> r. <br /> Signed .Title: Data: Z` <br /> FOR DEPARTMENT USE ONLY ` <br /> � <br /> Application Accepted by �_ ` Date ��Z Area 0 / <br /> Pit or Grout Inspection by Date Final Inspection by Date � 7�17 <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/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE �AMOUNT REMITTED CASH RECEIVf D BY DATE f PE^R7MIT`NO. <br /> + EH13-244REV.t/B57 ©( /D � � � �,� /•�,� J /rf�2 <br /> EH 14.28 / { ` <br />