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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 Or ance No.549 for sewage or No. 1862 for welUp p a d the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 1 <br /> Job Address �' r City Lot Size PM <br /> J <br /> Owner's Name Address.• Phone <br /> 'Contractor dress License IV .U Phone <br /> STYPE OF WELL/PUMP: ��i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ " 5Y§TEM REP,4j�it❑ , OTHER C ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES'. DISPOSAL FLD. PROP. LONE I' <br /> _ FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA./"C6NSTRl1CT(6N SPECIFICATIONS <br /> Dia'of Well Excavation Dia. of Well Casing <br /> El Industrial LJ Open Bottom 0 Manteca - ' <br /> ❑ Domestic/Private C Grave! Pack El Tracy Type of Casing Specifications <br /> h <br /> Type of Grout <br /> f"7 Public F1 Other Cl Delta Depth of Grout Seal YP <br /> 11 i Irrigation .Approx. Depth I 1 Eastern Surface Seal Installed by <br /> ',Repair Work Done ❑ Typf of Pump H.P. ' # :State Work Done <br /> °r 'Material (to o _ <br /> tWell Destruction ❑ Well Diameter Sealing p 50') <br /> I Depth Filler Material (Below 50'1 <br /> ;TYPE OF SEPTIC WORK: NEW INSTAL TION i REPAIR/ADDITION l_1 DESTRUCTION {rl (Nd septic system permitted if public sewer is <br /> available within 200 feet.) <br /> " Installation will serve: Residenceelk_ Commercial 'Other r <br /> iif r <br /> Number of living units: �pI' Number of bedrooms <br /> Character of soil to a depth! 3 feet: k f '� i Water table depth. <br /> U 0 f No. Compartments <br /> I <br /> SEPTIC TANK ❑ ;{Type/Mig Capacity p <br /> PKG. TREATMENT PLT. ❑ c '; Method of Disposa <br /> J <br /> "Distance to nearest: Well ,Foundation 10.1.f Property Line + <br /> I LEACHING )_INE ❑ °No. & Length of lines � To length/size <br /> r <br /> }FILTER BED ❑ distance to nearest. Well Foundation Property Lin i <br /> 1 SEEPAGE PITS I 1 i Depih ?/ Size ---War <br /> SUMPS D Distance to nearest: Well D FoundationProperty'`Line a <br /> DISPOSAL PONDS ❑ �" <br /> L p 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 S`an Joaquin Local Health District. <br /> f Home owner or licensed agent's signature certifies the following: "I certify�thatin.the'$erformance of,the work for which this permit is issued, I shall not <br /> k <br /> f employ any person in such manner as to become subject to warkmari's compensation,laws of California."Contractor's hiring or sub-contracting signature <br /> t certifies the following: '"I cert((y that in the performance of the'worg for which this permit is issued,t shall employ persons subject to workman's compensa- <br /> 3 tion laws of California. <br /> The applicant st call far all re red inspect ns. Complete•dr'a,wing on reverse side. <br /> Date: �~ <br /> Signed X . n Title: aeA <br /> �$y E FOR'DEPARTMENT USE ONLY r _ N nn�� <br /> 1 'Dl-att e Area rel <br /> Application Acr Dcepted by i <br /> Pit or Grout Inspection by Dat Final Inspection byY Date <br /> r A itional Comments: <br /> l Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71041 EJTracy 835-6385 <br /> A plicant - Return all copies;to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> F ' <br /> --FEE <br /> _ _.,..AMOUNT=DUE-»--�•—AMOUNT•REMiTTfg'�-* ^+�SHS '"RECEIVED BY °� "DATE" ^"� —PERM NT''NO <br /> INFO <br /> ' + EH 53-24{tiEV.k/ri 51 <br /> EH 14-26 u <br /> 'IM <br />