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/V JT ' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone {208} 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. e <br /> a <br /> Job Address City Lot Size C PM. <br /> I- <br /> I ' �� <br /> Owner's Name..' � Address � <br /> - P <br /> Phone03 �11 ' o? F <br /> Contractor Address 'Q4J License No. 3 nJ�J n�� Phony <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal' - ' Type of Grout <br /> i(Irrigation _Approx.Depth ❑ Eastern Surface,Seal Installed by i[ <br /> Repair Work Dane Type of Pump g / H.P. �I State Work pone �! <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth ` Filler Material (Below 50') <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is S <br /> t available 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: t 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 /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS Q Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ "l <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. ' V , - <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." y j* <br /> The applicant must call for all required inspection's. Complete drawing on reverse side. <br /> Signed Title: �^ r <br /> i <br /> `.=d � Date: `lad <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by Date ��Z. Area <br /> ' � i <br /> Pit or Grout Inspection by Date Fnal Inspection by 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO OO RECEIVED BY DATE PERMNO. <br /> (� �^ E T' <br /> + EH 1324fpEV.iiR51 J -CASH tfp�IfT' „ <br /> EH 1128 _ .. - <br />