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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 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 or No. 1862 for well/pump and the Rules wid Regulations of the San Joaquin <br /> Local Health-pistrict. <br /> ^ q / <br /> Job Address 1/ � � (-/ 1`t7 <br /> ! _ City Lot Size PM <br /> Owner's Name �ti�_�1-./— -f,e�_,1��,ii Ad rens 1 8 ,�_�/„�_ __ Phone <br /> J <br /> Contractor's Namecense No. ` Phone 10 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER Cl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER INES 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 WellIcasing <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 Istalled by ____.___—__ <br /> Repair Work Done ElType of Pump H.P. 1 State Work Done <br /> Well Destruction ❑ Well Diameter' Sealing Material (top 501 <br /> Depth Filler MaterK(Below 501 I Z <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: ResidencAber <br /> Commercial Other <br /> Number of living units: --k of bedrooms 0 (r� <br /> Character of soil to a depth of 3 feet: _ Water table depth e�) <br /> SEPTIC TANK ❑ T e/Mf C <br /> Type/Mfg g �.>!� Capacity No. Compartments <br /> PKG. TREATMENT PLT. O / ^ Method of Disposal /1 <br /> Distance to nearest: Well / i = Foundation_/ Property Line S <br /> LEACHING LINE A No. & Length of lines _Z. q 0 Total length/size <br /> FILTER BED ❑ Distance to nearest: ell!n 1 Foundation T3 Property Line <br /> —/ <br /> SEEPAGE PITS ❑ Depth a Number <br /> SUMPS Distance to nearest: WellFoundation _f�_ Property Line _e,.,re � <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. <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: "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." <br /> The applicant t r requir7o_ <br /> ctions. Complete dfawing on reerse side. <br /> Signed X / � �. . /Title: --,C-r! 7�! �� .�— Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <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/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE. PERMIT NO. <br /> y 14-26IREV. 10/831 11- o iL <br />