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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209).466-67$1 <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 -2-3 9y <br /> City O/r Lot Size PM <br /> Owner's Name � Address C. � <br /> Phone <br /> Contractor Address <br /> /cense Na.�Phone <br /> TYPE OF WELL/PUMP: S <br /> NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � i <br /> DISPOSAL FLp. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open BottomManteca Dia. of Well Excavation �r <br /> ❑ Domestic/Private Gravel Pack Dia. of Weli Casing <br /> ❑ Tracy Type of Casing <br /> ❑ Public Specifications �[ `� <br /> of GEl01her F-1DeltaDepth rout Seal <br /> Irrigation �q Type of Grout LP <br /> pprox. Depth Eastern S ace Seal Installed by -J3Repair Work Done ❑ Type of Pump H.P. / 4 •- <br /> State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (top 50') Z <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is (' <br /> Installation will serve: Residence_ CommercialOther available within 200 feet.) T <br /> L..• <br /> Number of living units: Number of bedrooms P <br /> Character of soil to a depth of 3 feet: -S <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Y Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED 11 Distance <br /> length/size <br /> Distance to nearest: Well Foundation ` <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS Number <br /> ❑ Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation• Property Line <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 they ork for which this permit is i ued, I shall employ <br /> tion laws of California." �j' p Y Persons su fact to wprk n' compensa <br /> �-�-.o~.�� ee�Cec ir.� y C. , c�c� <br /> The appli t ust call f all re ed inspections. Complete rd aging on reverse side. _ <br /> Signed Title: S <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by � Date <br /> Area <br /> Pit or Grout Inspection by -Date o2— 9-D-' <br /> rl Final Inspection by Oir Date <br /> Additional Comments: d C(eGOrp[!/� <br /> ❑ Stk 466.6781 ❑ Lodi 3699-3621 Manteca 823-7104 ❑ Tracy 5-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUM7 DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE <br /> EPERMIT'No. <br /> EH 14-26EK 13-24 1AEV.t/a51 e 1 _ P <br /> �-� XPrvi `Li ri C j <br />