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APPLICATION FOR PERMIT <br /> SAN JOAQ6IN LOCAL HEALTH DISTRICT' <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA M <br /> Telephone (209) 466-6781 I; "" <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) l j! <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 /> r <br /> Jab Address y,�.. '-�` , � City. of Size Vo� PM <br /> Owner'sAddress Name.. r5 73 li �QS-�Q 0 <br /> Phone <br /> n <br /> ContractorX 7V! Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL'D. PROP. LINE <br /> 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 /> Cl <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' <br /> F] Public Cl Other c Cl Delta Depth of Grout Seal Type of Grout <br /> ­ <br /> I Irrigation _..Apprpx, Depth l I Eastern Surface Seal Installed by "' <br /> Repair Work Done ❑ Type of Pump' H.P. State Work,Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION II REPAIR/ADDITION Ll DESTRUCTION {No septic system permitted if public sewer is <br /> vailable within 200 feet.) <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: I 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 /> j <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 1 <br /> 4. <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS ❑ Distance toynearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sari 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 thework 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 sigriature <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 ust II for all required ' s ctions. Complete drawing on reverse side. f f <br /> Signed X Title: Date: / er <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ~ 4 Area <br /> Pit or Grout Inspection by Date Final Inspection by � a A <br /> Ir Date e <br /> Additional Comments: U� <br /> ❑ Stk 466-6781 ❑ Lodi 369-362r 0 Manteca 923-7104 ❑ 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 DUEAMOUNT REMITCK <br /> NFO CASH BY DATE TE PERMIT'NO. <br /> If'JTED Q MI <br /> 4 + EH 14-24IREV,rin6f RI "(/y C.GJ/�- � "04 <br /> F EH �-28 OODU �L.J�^ <br /> I <br />