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x APPLICATIO,P1 FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELT ON AVE., STOCKTON .::CA <br /> Telephone (209) 466-6781 <br /> PERMIT-EXPIRES TYEAR 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 @pplication 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. ` a 5— <br /> i <br /> Job Address c City p Lot Size ` ___ f M <br /> Owner's Name 9/'�l.Ct/` ','+' 9Address C' � C��-' Phone <br /> Phon <br /> Contractor_ �I .! Address 4 �xC -� License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK f 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 L Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typa.of Casing Specifications <br /> M Public ❑ Other Cl Delta Depth of.Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. a / , `__- State Work Done_ t` <br /> Well Destruction ❑ Well Diameter Sealing Materal /top 50'1 (U <br /> Depth Filler Material /Below 50') <br /> .TYPE OF SEPTIC WORK: NEW INSTALLATION l 1REPAIR/ADbITI ONA DESTRUCTION I I (No septic system permitted if public sewer is <br /> '. available within 200 feet.! <br /> Installation will serve: Residence [Commercial_.,Other �� <br /> Ndrnb& of Ikin units: Z___ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK i7 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: Wel Foundation ,/ Property Line <br /> SEEPAGE PITS 11 Depth Size Number C?f� <br /> SUMPS 0 Dista ce to nearest: Weli / �fJ Foundation P operty Line <br /> DISPOSAL PONDS ❑ <br />'► I hereby certify that I have prepared this application and that the work vAll,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." 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 Califomi <br /> The applicant m t c>llf4r allreq c'ons. Complete drawing on reverse side. <br /> Signed XTitle: Date: <br /> FOR DEPARTMENT USE ONLY j <br /> A ticatian,Accepted by �� Date Area f <br /> nut+Inspection by DateFinal Inspection by Da <br /> y <br /> Additional Comments: � � <br /> ❑ Stk 466-6781 ❑ Lodi 369-361 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-21/REV.i i k 51 O, ' <br /> 11 <br /> ' EH 11-25 / <br />