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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA �QJ <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 and Regulations of the San Joaquin <br /> Local Health District- <br /> -Job Address L Cityl rte- Lot Size,3,27 X(, 3Z­PM <br /> • - <br /> Owner's Name44,_aA _ Adddress �i 0 '�'G Phone U' ' <br /> Contractor t ` r ' ddress a?,M L License No./ t3J L3 �(f Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYS EM REPAIR ❑ OTHER ❑ <br /> y DISTANCE TO NEAREST: SEPTIC TANK SEWE LINE DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRIC LT E WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom O Manteca Dia_ of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> [-I Public Fl Other ❑ Delt Depth of Grout Seal Type of Grout <br /> I I Irrigation —,Approx. Depth ! 1 stern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump N.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 REPAIR/ADDITION I I DESTRUCTION 1-1 (No septic system permitted if public sewer is <br /> available within 200 feet.) 1 <br /> Installation will serve: Residence/ Commercial�-Other 1 <br /> Number of living units: Number of bedrooms n <br /> Character of soil to a depth of 3 feet: / Water table depth (� <br /> SEPTIC TANK ❑ Type/Mfg 1 1 Capacity tJ No. Compartments <br /> PKG. TREATMENT PLT. ❑ ty L e��X <br /> y ,21 <br /> Distance to nearest: Well �f`� e7 Foundation Property Lin j O <br /> LEACHING LINE ❑ No. & Length of lines t To al length/size <br /> FILTER BED ClDistance to nearest: Well 14LFoundation- r Property Line <br /> / <br /> SEEPAGE PITS 11 Depth Size < Number <br /> _ SUMPS [l Distance to nearest: WellITUAA)undation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 st call for_a1 bquired i spections. Complete drawing on reverse side. <br /> . .� 4� / ,F.�i -- Date: <br /> Signed X � Title: �l �1 <br /> OR DEPARTMENT USE ONLY ` <br /> Application Accepted by C 1 Date two- Area <br /> Pit or Grout Inspection by Date Final Inspection by,/ <br /> 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 t' <br /> FEE �70,& <br /> UE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH1}-2.(REV.I/h514-26 <br />