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(� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 /> -✓� ^� <br /> Job Address City Lot Size PM <br /> r <br /> Owner's Name X"*/#AAddress Phone <br /> Contractor � ��. ��_Address License No.!� .�Phone <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 /> I'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation .Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will server°!Residence Commercial Other <br /> Number of living units:; Number of bedrooms T <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 IT Total length/size <br /> o nLine— <br /> SEEPAGE <br /> S� O <br /> FILTER BED °'Q� Distance tearest: Well Foundation� Property Line �d 1 <br /> SEEPAGE PITS l I_ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 _J <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, 1 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." r <br /> The applicant must call f I uired in tions. Complete drawing on reverse side. <br /> Signed X Title: /JT ­�! r®�' Date:�,fl <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 2 �� Area .2__l <br /> CW <br /> Pit or Grout Inspection by Date Final Inspection by ' Date <br /> Additional Comments: LTJ C <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 <br /> INFO AMOUNT-DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"NO. <br /> + EH 13.24 1REV.I i H 5) c7Z <br /> ^-7 <br /> EH 14-26 l ���2/9- <br />