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APPLICATION FOR PERMIT <br /> 0 y1� <br /> SAN JOAQUIN LOCAL:HEALTH DISTRICT <br /> 1601 E. HAZE ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 4 <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 r No. 1862 r well/pump d the Rules and Regulations of the San Joaquin <br /> Local Health District. J " <br /> Job Address �r �r '�"''`" I-`L *~' ' City Lot Size PM <br /> Owner's Name Ur!'Address lJ��� CI -f`zJr�F L Phone <br /> J{� � / <br /> Contractor ^=' Address / �O License'No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑,,' SYSTEM REPAIR [;�/ OTHER ❑ t (� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca 1­•.1 Dia. of Well Excavation I _ Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ TVacy.`-- v Type of Casing I Specifications <br /> 2^Public ❑ Other 71 Delta�y^a r Depth of`Grout Seal i _ Type of Grout <br /> ❑ Irrigation ---Approx. Dnpth ❑ Eastern 4 {Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump 1- ,� P,._? State Wor0 Donee <br /> : � '. t <br /> Well Destruction 11 Well Diameter i Sealing Material (top 501 <br /> Depth Filler Material [Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 1 REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is <br /> ! available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other — k <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: `Water table depth <br /> i <br /> SEPTIC TANK ❑ Type/Mfg i Capacity sNo. Compartments 1 <br /> PKG, TREATMENT PLT. ❑ (, Method of Disposal <br /> Distance to nearest:. Well Founda�ion, 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 �_,. ❑ DepthNumber <br /> Size r <br /> - f�' <br /> SUMPS i❑_ ._OisiBn to nearest: , Well _ FoundationProperty4Line <br /> DISPOSAL PONDS I]- <br /> I hereby certify that I have prepared this application ana that the work will be done in accordance with Sa Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. it <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." Giontractor'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." E <br /> t f <br /> The applicantt call for all required inspect' ns. Complete drawing on reverse side. <br /> TuF <br /> Signed )( ' !�''Fitle: Data: T/ v <br /> FOR DEPARTMENT+USE ONLY <br /> Application Accepted by Date r Area <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by 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/Serviceh'1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. <br /> INFO CASH <br /> +EH 13-244REV.1/6.5} � Q� <br /> EH 14-28 <br />