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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE`TON 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 weir/pump and the Rules and Regulations of the San Joaquin <br />Local Health District. <br />1 City � Lot Size t.��'� UL.� _ PM <br />Job Address sa6 <br />Owner's Name — Address hone <br />CQ �-p <br />Contractor Address License No. _ `moo Phone <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O <br />PUMP INSTALLATI N ❑ SYSTEM PEPAIR ❑ OTHER s6l j 'f '�StU1c <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LPROP. LINE � <br />FOUNDATIONS } _ AGRICULTURE WELL Q[KOTHER WELL N PITS/SUMPS _ <br />INTENDED USE <br />❑ Industrial <br />❑ Domestic/ Private <br />I I Irrigation A"61 I <br />Repair Work Done ❑ <br />Well Destruction ❑ <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br />❑ Gravel Pack ❑ Tracy Type of Casing e <br />Cl Other n Delta Death of Grout Seal F <br />—Approx. Depth I I Eastern Surface Seal Installed by <br />Type of Pump H . State Work Done <br />Well Diameter Sealing Material Itop SO1 <br />Depth Filler Materiai 180low 501 <br />NEW INSTALLATION I l REPAIR/ADDITION I I DESI <br />Dia. of Well Casing .I3011r <br />Specifications <br />Type of Grout i_. <br />1 I INo septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence _ Commercial o Other <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth _ <br />SEPTIC TANK O Type/Mfg Capacity No. Compartments . <br />PKG. TREATMENT PLT. ❑ Method of Disposal . <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE ❑ No. A Length of lures Total length/size <br />FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS I I Depth Size Number <br />SUMPS 0 Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS ❑ <br />1 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 Di§trict. <br />Honor owner or licensed agent's signature certifies the following: "I certify that in the perfomtance of the work for which this pwn-dt 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 subcontracting signature <br />certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ perms subject to workman's compensa- <br />tion laws of California." <br />The applic t call for all required inspections. Complete drawing on reverse side. <br />Signed D:ARTMINT <br />f— Date: 7 � l u� <br />FOR USE ONLY <br />Application Accepted by <br />Date <br />Pit or Grout Inspection by Date Final Inspection by <br />Area <br />Additional Comments: <br />O Stk 1 O Lodi 369-3621 O Manteca 823-7104 O Tracy 83543386 <br />Applicant - Return an copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />s, EH 13.24 IREv. I/ As <br />614 16.% <br />Date <br />FEE <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CK 9 CASH <br />RECEIVED BY DATE PERMIT' NO. <br />INFO <br />