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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT cy <br /> 1601 E. HAZE TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE IS-SUED V I <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 40!P1. City Lot Size <br /> �e4 V PM_ <br /> Owner's Name Address P <br /> Phone <br /> Contractor <br /> "s— L< No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT D DESTRUCTION U <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 <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 /> 0 Industrial 0 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> El Public El Other 0 Delta Depth of Grout Seal Type of Grout <br /> El Irrigation --Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done <br /> Type of Pump edz-_4 H,P, Z&&e — State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION ED DESTRUCTION 0 (No septic system permitted if public sewer is <br /> • <br /> Installation will serve: Residence— Commercial— Other available within 200 feet.) <br /> Number of living units: — Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK El Type/Mfg Capacity— No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Property Distance to nearest: Well Foundation <br /> _ Line <br /> LEACHING LINE El No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well <br /> Foundation— Property Line <br /> SEEPAGE PITS 0 Depth Size Number <br /> SUMPS 0 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:"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�all f 7 allure ' d ctions. Complete drawing on reverse side. <br /> Signed X Title: Date: -911ZV1X9 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by M 1 Date 10—fa- Area <br /> Pit or Grout Inspection by Date— Final Inspection by Oyvx Datd.d —f <br /> Additional Comments: 5 A_&;� <br /> 0 Stk 466-6781 0 Lodi 369-3621 El Manteca EM-7104 0 Tracy 835-6385 11 a?rve s C4-,r tQ e�-s res i'�e,,c e <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 CK#/ <br /> INFO bk9H RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24(REV.1/8 5) <br /> EH 14.16 WOCL_ <br />