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I ' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F#. 1601 E. HAZELTON AVE., STOCKTON, CA O � Ltd <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> v <br /> � . <br /> r u <br /> Application is hereby made to the San Joaquin Local (Complete in-Triplicate) <br /> 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 /> - -• City Lot Size PM <br /> c _ <br /> Owner's Name G Y ~ Address � S ��� Fj <br /> Phone a t� <br /> I ContractorAddress <br /> TYPE OF License No. Phone <br /> WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f] industrial ❑ Open Bottom ❑ Manteca Dia. of We11 Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack Dia. 0f Well Casing <br /> ❑ Tracy Type of Casing <br /> FI Public f] Other 1-I Delta Depth of Grout Seal Specifications <br /> I I Irrigation Type of Grout <br /> —.Approx. Depth (.I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. _ <br /> Well Destruction El Well Diameter MStare Work Done <br /> Sealing Material (top 50') <br /> F,+T Depth Filler Materia! (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTIO (No sepA.Pth <br /> ermitted if public sewer is <br /> Installation will serve: Residence . available feet.) <br /> Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Wepth <br /> 4" ❑ Type/Mfg Capacity Noents <br /> PKG. TREATMENT PLT. ❑ <br /> MeposaiDistance to nearest: Well FoundationProperty LEACHING LINE ❑ No. & Length of lines <br /> FILTER 8ED Total length/size <br /> ❑ Distance tonearest: Well FoundationProperty <br /> SEEPAGE PITS - 11 Depth Size <br /> SUMPSL� DiNumber <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ., ❑ Property Line <br /> A <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 fallowing: "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 <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ <br /> tion laws of California." p p y persons subject to workman's compensa- <br /> tion <br /> The applic si calf for all requir inspections. Complete drawing on reverse side. <br /> Signed Title: � �? <br /> �`' Date: <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by �� <br /> Date � Area <br /> Pit or Grout Inspection byDate <br /> Final Inspection by Date <br /> Additional Comments: /C fr � �9 r % /! <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71040 Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave P.O. Box 2009, Stk., CA 95201 <br /> � FEE <br /> CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE3 <br /> r+ EEH <br /> H 1424(REV.rind PERMIT"l�D. <br /> 1' <br />