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a i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 1 <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> i <br /> Job Addresses �l/��°- City A.-4 Lot Size PM <br /> ! i <br /> -)(Owner's Name L Address Phone �- Of X.J 1 <br /> � I <br /> ,.,/ Contractor Address License No. Phone - 1 <br /> a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM RE AIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER Ll DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO TR TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well avation Dia. of Well Casing r_ <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingN <br /> Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of GroutType of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal InRepair Work Done ❑ Type of Pump N.P. k Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 lcx� <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'[1 REPAIR/ADDITION I I 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: 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 /> LEACHING LINE ❑ No. & Length of lines Total length/size { <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS it Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 shalt 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 taws of California." <br /> The applicant must call for all required inspections. Complete drawing on r verse side. <br /> l <br /> Signed X Title: Date: �vI � q <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by ✓ Date b~� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date C �7 ��� <br /> Additional Comments: — �- <br /> ❑ Stk 466-6781 O Lodi 3'89-3671 ❑ 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 /> r <br /> CK <br /> FEE AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED BY 4 DATE PERMIT NO. <br /> INFO _ _ <br /> +.EH 1324 iREV,t i h 51V U(' t� (� CQS /,!� /0 <br /> EH 14-26 <br />