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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.;STOCKTON, CA <br /> Telephorle (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 Addressr <br /> ,/� _ City ew Lot Size,;Z;�U r?t'_ Lfd PM <br /> Ownel+l:ame , ons v e <br /> .Address <br /> i Contractor / Address �V1 d Phone ' <br /> License No. d <br /> TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER J' &0044 <br /> F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE � + <br /> I` 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 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1`I Public Cl Other n Delta Depth of Grout Seal Type of Grout—__,.___. <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal.lnstalled by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done _ <br /> Well Destruction ❑ Well Diameter rear,y"nrmmTft 50.1 e }• + t �, <br /> Depth ,.Mlle 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITEON I I DESTRUCTION I I iNo septic system permitted if public sewer is <br /> available within 200 test.? <br /> Installation will serve: Residence Commercial_ 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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> f Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED - ❑ Distance to nearest: Well_ Foundation Property Line <br /> SEEPAGE PITS I I Depth _ Size Number w <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 all <br /> fired inspections. Complete drawing on reverse side. <br /> Signed X Title: " Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date " tb <br /> s <br /> Area <br /> Pit or Grout Inspection by Date .Final Inspection by -01 Date <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 /> ► <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y <br /> INFO CASH DATE PERMW NO. <br /> ♦ EH 13-74 IREV.I/x 51 / 1 <br /> EH 14-26 i! 1 .,Z :•jcl-:. ''~�/'^._._,y�. p^ -M,- <br />