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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> .Application is heieby 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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. li <br /> �, Ne9.✓T City Gem/ri Lot Size C• PM <br /> Job Address i ' <br /> Owner's Name ��' �� Address 7 <br /> /L1D 7 r �f WAI7-` Phone <br /> Contractor <br /> S�Cf Address License�No. Phone_ <br /> ` TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR # OTHER ❑ _ <br /> DISTANCE TO NEAREST: S6TIC TANK Z02 SEWER LINES jT_— DISPOSAL FLD. PROP, LINE �7'r• <br /> s FOUNDATION /Ba — AGRICULTURE WELL OTHER WELL— <br /> .4 <br /> INTENDED USE a TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI A IONS de <br /> Vp <br /> ❑ Industrial Id Open Bottom ❑ Manteca l Dia. of Well Excavation <br /> Dia. of Well Casing <br /> DomesticlPrivate LJ Gravel Pack ❑ Tracy` Type of Casing Specifications O <br /> µ� Tn Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout <br /> I Irrigation 11..Approx. Depth <br /> 1 Eastern Surface Seal Installed by - <br /> i e of Pump �+'�"' H.P. —S� State Work Don <br /> Repair Work Dane r Typi <br /> �WeN Destruction ' ❑ Well Diameter .._.,— Sealing Material Itop 50'1 — <br /> Depth �A Filler Material (Below 501 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION l 1 (No septic system permitted if public sewer is 1 <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br />} Number of living units: �! Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ 'Type/Mfg Cap No. Compartments <br /> j PKG. TREATMENT PLT- ❑ Method of Disposal r <br /> t <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHINGLINE OfNo. & Length of lin Total length/size <br /> FILTER BED ❑ ' Distance to rest: Well Foundation Property Line <br /> SEEPAGE PITS l I '�M epth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL P ❑ <br /> I her ertify 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, l shall not <br /> r employ any person in suchmanner 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 /> 11' tion laws of California." �� V <br /> Theapplicant must call al reqed inspections. Complete drawing on reverse side. <br /> ��,j%¢Signed X � _ Title: Date: <br /> -- --w� FOH DEPARTMENT USE ONLY <br /> Application Accepted b date Area <br /> Pit or Grout Inspection by �l Date Final inspection by Date <br /> Additional Comments: „ <br /> 4 ❑ Stk 466-6781 ❑ LI`odi 369-3621 r 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 RECEIVED BY DATE PERMIT'NO. <br /> INFO .1 <br /> � EH 13-24IREV.tin51 <br /> EH 14-26 1 y <br />