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APPLICATIO.N.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE.,;STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> M PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> b° *. .a (Complete in Triplicate) �, x <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. 1662 forwell/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> rE <br /> Job Address aJ? City t I, Lot Size . ,4,chc pM 4 <br /> t QQ <br /> Owner's Name - Y Address /2J1a Phone <br /> Contractor Address Ofd? c]`� �1f t <br /> +�, License No. c2� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Z SYSTEM REPAIR ❑ OTHER ❑ S <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> M ^� 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 /> Domestic/Private ❑ Gravel Pack j ❑ Tracy Type of Casing Specifications l/�\ <br /> ❑ Public ❑ Other ' ❑ Delta Depth of Grout Seal * _ .. Type of Grout 1 <br /> ❑ Irrigation _ f _"_q <br /> pprox. Depth Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. 3 State Work Done I � r <br /> Well Destruction ❑ Well Diameter 1! ! <br /> Sealing Material (top 501 <br /> Depth Filier Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> Installation will serve: Residence, Commercial— Other available within 200 feed <br /> Number of living units: Number of bedrooms �. 1 <br /> Character of soil to a depth of 3 feet: <br /> '� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Wel! FotJndation Property Line <br /> LEACHING LINE ❑ No. & Length of lines f `, Total length/size <br /> FILTER BED ❑. Distance to nearest: Well ! 'Foundation Property Line <br /> � r ' <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Wel Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and`t`hat the work will be done in accordance with San Joaquin county ordinances, state laws, an { <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 all required inspections. Complete drawing on reverse side. <br /> Signed X - Title: <br /> Date: <br /> OR DEPARTMEN SE ONLY <br /> Application Accepted by Date �� r Area Y <br /> Pit or Grout inspection by ! Date <br /> Final Inspection by Date <br /> Additional Comments: � �f <br /> ❑ Stk 466-6781 ❑ Lodi . 369-3621 ❑ Manteca 823-710.4 ❑ 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 6Y DgTE PERMITNp, i <br /> INFO GASH <br /> +'EH13-24[REV. <br /> EH l4-ze <br />