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APPLICATION FOR PERMIT <br /> ' _., •.w•'i,.may <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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.. �/ <br /> Job Address o2 !V,5-- �� 9.4677-- 1�A PO N S*7— Lot Size PM <br /> Owner's Name f/i�l�iY/ �}L'�+'ci�+.d/` Address A5 Aa4a 91 Phone r� j <br /> Contractor. - y Address License No. Phone <br /> TYPE OF,WELL/PUMP: „ i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ` PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK -'20 67- 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 /> 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Ot6er- ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ irrigation Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIREPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is <br /> ailable within 200 feet.) <br /> Installation will.serve: Residence Nvd Commercial_ Other 1V <br /> Number of living units: f Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ' ,Type/MfgCapacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE` ❑ No. & Length of lines 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 ❑ <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 must call for A required inspections. mplete drawing on reverse side.. <br /> Signed Title: Date: 3 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 1 'Y Area <br /> Pit or Grout Inspecti � Date Final Inspection by Date <br /> Additional Comments- In <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK§R CK RECEIVED BY DATE PERMIT'NO. <br /> 1 X3-24[REV.F/135) <br /> hbh� <br /> Y <br />