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APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> �5 m, <br /> 1601 E. HAZEL T ONr AVE., STOCKTON, CA <br /> Telephone 4209) 466-6781 i <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. •+ <br /> Job Address Lot Size PM <br /> ._� JQ S/�D , <br /> = Owner's Name �} IAddress=� ` Phone <br /> Contractor &ghf Address_/���� is cpue� .G( License No._z—cr P I8 <br /> TYPE OF WELL/PUMP: NEW WELL' ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r��.y,r,,�b �K•�' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR P. LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS <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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j <br /> ❑ Public ❑ Other --- --., F-1DeltaDepth of Grout Seal Type of Grout <br /> ElIrrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 50') <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 /> available within 200 feet.) 111 i <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms - G <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.❑ 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' «,x <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." Lk <br /> The applicant st call for all requir inspections. Complete drawing on reverse side. <br /> . r <br /> Signed X Title: � +s/ _ Date: <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted byDate 17 4 Area <br /> Pit or Grout Inspection by Date Final Inspection by <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 CK# RECEIVED 8Y DATE PERMIT"NO. <br /> INFO CASH <br /> + EH1324(REY.tias) 1V � �1 <br /> EH 1426 <br />