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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTS <br /> 1601 E. HAZEL T ON 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Joh Address0 yh G <br /> /� City c�Fo� Lot Size PM <br /> Owner's Name J�I►t 5 [7i4 gddress +4L SA—L­ <br /> I Phone <br /> - <br /> Contractor's Name X41Y k 't Sy»`� License No. 7- Y14-2 4 3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Phone 7��` g� 4-7 <br /> PUMP INSTALLATION ❑ DESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES --�� DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PETS/SUMPS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> Dia. of Well Excavation Dia. of Well Casing ff <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy T <br /> ID Public ype of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Sealr <br /> 171 Irrigation Approx. Depth ❑ Eastern Surface Sea! Installed by Type of Grout <br /> Repair Work Done ❑ Type of Pump H P <br /> State Work Done <br /> Well Destruction ❑ Well Diameter �1 <br /> Sealing Material {top 50'j �C' <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDlTION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> 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: �e <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line I� <br /> SEEPAGE PITS ❑ Depth Size r�{ <br /> SUMPS ❑ Distance to Number V . <br /> nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> r <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." Contractors 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 <br /> tion laws of California." P Y Persons subject to workman's compensa- <br /> tion <br /> applicant ust all for all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3 <br /> Area <br /> Pit or Grout Inspection by Date <br /> Fina! Inspection by Date <br /> Ad itional Comments:- <br /> Ad <br /> 466-6781 ❑ Lodi 369-3621 ❑ Manteca '823-7104 ED Tracy 835-6385 <br /> plicant- 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 CASH RECEIVED BY DATE <br /> PERMIT NO. <br />+ EH 1324 IREV-10183) <br /> EH 1426 <br />