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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> A <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 /> a <br /> Local Health District. }- <br /> Job Address City t- Lot Size PM <br /> OF-2 QCA 15 <br /> Owner's Name �lS �V � AddressNAEZ Phone <br /> Contractor qE: T Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ ! <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI S DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTUR OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NS UCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of I Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy }Type of Cass Specifications <br />_ f l Public (� Other fl D Depth of Gro\n.,. d <br /> Type of Grout <br /> I I Irrigation —Approx. Depth I astern -Surface Seal by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> - - h <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') `1 <br /> - + Depth - Filler Material (Below 50'1 <br /> y TYPE OF SEPTIC WORK: NFW INSTALLATION REPAIRJADDMON l I DESTRUCTION I 1 o septic system permitted if public sewer is 1 <br /> t' '' available within 200 feet.) <br /> t <br /> Installation will serve: Residence , Commercial_ Other �, <br /> Number of living units: --I— Number of bedrooms i <br /> Character of soil to a depth of 3 feet: Water table depth 1k <br /> SEPTIC TANK _�7ype/Mfg Capacity No. Compartments 't <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: <br /> Well�. �...-._- foundations Property Line <br /> LEACHING LINE -No. & Length of lines Total length/size 19 <br /> FILTER BED ❑ Distance to nearest: Well I'lD f Foundation 5'Q f Property Line 0 <br /> SEEPAGE PITS I I Depth Size fl — Number 2- <br /> SUMPS Distance to nearest: Well Foundation 100 Property Line S <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 Local Health District. v <br /> Hume 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur <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 compensaa- <br /> tion laws of California." <br /> The applicant must all II require n pections. gomplote drawing on reverse side. <br /> Signed X Title: Date: <br /> EPARTMENT USE ONLY <br /> Application Accepted by Date -9-Is Area <br /> Pit or Grout Inspection by Date Final Inspection by QusA Date w� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> f INFO (� t�`1 GASH <br /> f + EH 1�24IREV.)"t) \.! !Q b� ISA^' <br />