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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> J 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 Joaquinmy 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 /> v, �`e Xa A <br /> Job Address City Lot Size PM <br /> �t& �� 4��- �r 4 <br /> Owner's Name V � 1�` AddressI. Phone <br /> [�yyam.� I <br /> Contractor Address C.LJ b _ icense No. Phone i <br /> TYPE OF WELL/PUMP: NEW WELL ❑, : WELL REPLACEMENT I-] DESTRUCTION ❑ II <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 /> Fl Public CI Other Ll Delta Depth of Grout Seal Type of Grout _ <br />* I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done 11 Type of Pump H.P. State Work Done ° <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR1ADb[TION - DESTRUCTION I I (No septic system permitted if public sewer is M <br /> available within 200 feet-) <br /> Installation will serve_ ResidenceCommerciaE ether \ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> j SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 4 <br /> j PKG. TREATMENT PLT. 0 Method of Disposal I <br /> Distance to nearest: Well Foundation Property Line <br />�I <br /> I LEACHING LINE ♦'f� <br /> l No. & Length of lines 0f Total length/size r <br /> t FILTER BED ❑ Distance to nearest: Well Foundation ' Property Line <br /> j SEEPAGE PITS 11 Depth Size Number <br /> t <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 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 <br /> certifies the following:"!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 alifomia."" <br /> fThe,appli must c I tall r aired inspections. Complete drawing on reverse side. ' I <br /> Signed Title:_ Date: ho <br /> f <br /> E FOR DEPARTMENT USE ONLY i <br /> J Application Accepted by w� Date'£ 3V Area <br /> 01 <br /> Pit or Grout Inspection by Date Final-inspection by i - - Date <br /> Additional Comments: 2f.R�r 1 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104CJ Tracy 835-6385 <br />� Applicant- Return aft copies to: Environmental Health Permit/ServicesG1601 E. Mazelton Ave., P.O. Box 2009, Stk., CA 95.201 <br /> IFEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO: <br /> tNF0 '/--��C,jASH <br /> `'0 c 0-0 �o r O� f'_�G112 <br /> EH 14-28 v I J U <br />