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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT S�L(\ <br /> 1601 E. HAZETON 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 and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 7549 a ,4 C IV L! 'Jy City S�G Lot 5izs X�l� PM <br /> Owner's Name C"7 ,, /Y! if K4f 7_1— Address9. r Phon <br /> I <br /> Contractor s �� Address �7 License No. Phone , <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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`11t;,t'PROBLEMAREA CONSTRUCTION SPECIFICATIONS: <br /> ❑ Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C <br /> ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing #_ Specifications <br /> ❑ Public ❑ Other ❑.Delta Depth of Grout Seal f Type of Grout <br /> ❑ Irrigation --Approx. Depth` ❑ Eastern. Surface Seal installed by <br /> Repair Work Done F1Type of Pump j' `° H.P. ti '12 State'Work Done 1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 r <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200 feet.)' <br /> Installation will serve: Residence_ Commercial Other •- _ _ _ °- x <br /> Number of living units: Number of bedrooms I <br /> Character of soil to a depth of 3 feet:• - Water table depth <br /> SEPTIC TANK Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ., <br /> LEACHING LINE Llh o <br /> No. & Lengtf lines'4. Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth---.---- Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <br /> I hereby certify that 1 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 must call for all required inspections. Complete drawing on reverse side. <br /> `f Signed <br /> ' Title: Date: <br /> 7� FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �' Area O <br /> pp P <br /> {� <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> r <br /> i` Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83540%i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. <br /> INFO �y '� CASH gn <br /> + EH 13-24(REV.1/e 5) P�T(7 - / ^���"(J <br />{ EH W28 /� <br />