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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 7 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 Ordinanqe Np.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 194 <br /> 1�. I £ W <br /> jLp <br /> Job Address j Q "�� 9l`'��_�-- J' City of Size �� PM <br /> Owner's Name ddressPhon3 33 <br /> e <br /> Contractor's Name License No. Phon`e3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Q <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' COZZ, <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing <br /> Ll Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing �` Specifications <br /> ❑ Public ❑ Other Q Delta Depth of Grout Seal Type of Grout 01\ <br /> ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by �hCl <br /> Repair Work Done Q Type of PumpH.P. tate Work Done <br /> Well Destruction :' ❑ Well Diameter Sealing Material {top 50') <br /> Depth Filler Material (Below 50') Y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITlqr DESTRUCTION ❑ (No septic system permitted if public sewer is . <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms j !` J <br /> Character of soil to a depth of 3 feet: - Water table depth {� <br /> SEPTIC TANK ❑ Type/Mfg Capacity J - 'No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> a Distance to nearest: Well Foundation Property Line <br /> ` Il <br /> LEACHING LINE ?7No.'& Length.of lines Trot%� length/size <br /> FILTER BED ' Distance to nearest: —Well F Foundation _`'Property Line <br /> SEEPAGE PITS' Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well 1 Foundation � / Property Line <br /> DISPOSAL PONDS 71 <br /> hereby certify that I have prepared this application and that the work will be 1dorie 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 fallowing: "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 in the performance of the work for which this permit is issued,I shall employ ersons subject,to workman's com en '� <br /> P YP J p so-:. <br /> tion laws of Cali r a." ,� <br /> The applicant us call for d ins pe ons. Complete drawing on reverse side. <br /> SignedY f <br /> Title: Date: S7/ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by x i i F <br /> _ Date � -50 Area 40 <br /> Pit or Grout Inspection by Date U 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 AMOUNT DUE AMOUNT REMITTED RECEIVI D BY DATE PERMIT`N0. <br /> INFO FI <br /> + EH 1324{REV.16/831 ". A a I <br /> EH 10.26 - -7 c> • ,a `10� O.p �lo �•3J <br />