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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 9 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Appiication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applicationis' <br /> made in compliant w th San J um Cou Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San�loajuin <br /> Local I'el :. <br /> J ' l /�. O <br /> Job Address j7 V��' r City. Lot Size PM <br /> Owner's Name -'6a—<­Address / 4,4 y Phone <br /> Contractor's Name License Na. Phone <br /> YJ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT II f 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 (top 501 <br /> Depth Filler Material [ elow 50:}) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONX DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> Y available within 20D feet.) <br /> Installation will serve: Residence Commercial__Other � <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 I Capacity No. Compartments <br /> _PKG. TREATMENT PLT. ❑ t+ Method of Disposal k <br /> Distance to nearest: Well Foundation Property Line <br /> _21LEACHING LINE No. & Length of lines ~ ,T,otal length/size <br /> FILTER BED El Distance to nearest: Well s Foundation '�,� !--Property Line L� ' <br /> SEEPAGE PITS ❑ Depth Size 1 l Number • <br /> SUMPS ❑ Distance to nearest: Well x"—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 /> ruies 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 I„Y <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.” t <br /> The appan all for all rCqu_ire_d'Npectiqnk. Complete drawing on reverse side. ' <br /> Signed itle: Date: VIM- <br /> -.. } <br /> FOR-DE�FRTTNJE�N_6SE'.ON�LY x k <br /> Application Accepted byDate `� Are <br /> Ph or Grout Inspection by Tate 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/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED F1 RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> a Eli 13-24 IREV.101631 +S� U-a DZ-77 <br /> EH 1426 _ <br />