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I! 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 wellipump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> � li <br /> .I <br /> Job Address w City Lot Size PM <br /> s <br /> eaos� <br /> Ownr's Name Address Phone <br /> Contract Lark C-c4 Addressp.10 .ae<55' s 4;W2 <br /> License Noz!X&Phone <br /> TYPE OF WELL/PUMP: it 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation ►,Dia. of Well Casing <br /> ❑ Domestic/Private CGravel Pack ID Tracy VP 9 Trac T e of Casing f <br /> Specifications <br /> I'? Public ❑ Other Ll Delta Depth of Grout Seat Type of Grout <br /> I ( Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter _ Sealing Material (top 50'1 <br /> Depth'I Filler Material (Below <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION I I REPAIR/ADDITION ESTRUCTION i I (Noave septic system permitted if public sewer-is v <br /> �I available within 200 feet.) <br /> Installation will s8rve: Residence— Commercial�0ther <br /> Number of living units: ,Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ <br /> I ► Method of Disposal <br /> Distance to nearest: Well�b Foundation"310 Pr f <br /> Property Line <br /> LEACHING LINE No!'& Length of lines Total Length/sizeSir <br /> FILTER BED ❑ Distance to,nearest: Welt Foundation Property Line <br /> J uv_ <br /> SEEPAGE PITS l I Depth SizeB <br /> Number <br /> SUMPS Ll Disilance to nearest: Well <br /> FoundationProperty Line ` <br /> DISPOSAL PONDS ❑ ;I _ - .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 Heatth Di§trict. <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 parson in h manner'as to become biect to workman s comperisafran laws of Califoinia:"'Contraatoes-hiring•orsub-contracting signature <br /> certifies the following: certify tha4 in the pert nce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion Laws of Latif i I1 1 _ _ —,- _ __w�� <br /> The appli nt t II for all requir ns tion . CO ete ng on reverse side. II <br /> i <br /> Signed X �� f <br /> Title: I Date: <br /> FDR DEPARTMENTi USE ONLY <br /> Application Accepted by 1 DateArea I <br /> Pit or Grout Inspection by Date Final Inspection by=4Date /! FJ <br /> I; _ <br /> Additional Comment; <br /> ❑ Stk 466.6761 ❑ Lodi 36.43621 ❑ Manteca 823-7104 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEL: AMOUNT DUEAMOUNT REMITTEDCK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> ,.EH 13-24 iREV.i/H ss <br /> EN 1426 <br /> i <br />