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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA ° <br /> ephone (200) 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. THs 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 <br /> O rrr P� <br /> r— Ci Size PM <br /> Owner's Name CIC�1—Address r �4� r� d Phone / '~ 0 K <br /> Contractor3� l . dress 1Oy !\ I ( License No, 6 Z 37 Phone <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR`❑ OTHER ❑ <br /> DISTANCE 70 NEAREST: SEPTIC TANKSEWER LINES i° DISPOSAL FLD. PROP. LINE \ <br /> - ."z'FOUNDATION - AGRICULTURE WELL ' OTHER WELL' PITS/SUMPS i <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 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation Approx. Dept ❑ Ea ern Surface Seal Installed by <br /> Repair Work Done C�/Type of Pump H.P. 1 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <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.) <br /> Installation will serve: Residence— Commercial_ Other 's, <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth t7 <br /> SEPTIC TANK ❑ Type/Mfg " Capacity _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ `y 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. --� R'­Foundation t :Property Line <br /> SEEPAGE PITS ❑ Depth SizeNumber' <br /> SUMPS ❑ Distance to nearest: .Well <br /> Foundation Property Line , <br /> DISPOSAL PONDS ❑ O f <br /> I hereby cerci hat I have.p ared this application and that the work°will be done in accordance w0h San Joaquin county ordinances, state laws, and <br /> rules and re ulations of the Sa Joaquin Local He Ith District. ' <br /> Home ow or or licensed agent' signature certifi the follovri 'l certify that in the performance of the work for which this permit is issued, i shelf not l <br /> employ y person in such man r as to beco s bj to o man's c mpensation laws of Califoma."Contractor's hiring or sub-contracting signature <br /> certifie the following: " certi that in th perf r a of e o for ich this pe is issued, I§hbil employ persons subject to workman's compensa- <br /> tion la s of California. <br /> The a plicant must 11 requir in plate dra ng on rave ,. •— <br /> V �Q p <br /> Signe ,.itle: C` 'Date: l Q F <br /> R 'F0R,A113 TMENT USE ONLY <br /> Application Accepted y bate Area r <br /> Pit or Grout Inspect y Qate Final Inspection by Date Z� <br /> Additional Comments: <br /> ❑ Stk 4664MI ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,rStk., CA 95201 <br /> FEE INFO AMOUNT DUE. AMOUNT REMITTED GASH RECEIVED By DATE PERMIT"N0. <br /> + EH1&24(REV.I/R 5) <br /> EH 1426 <br /> s <br />