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APPLICATION FOR PERMITS�(p <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 w�L <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) �vi1 <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 Sart Joaquin <br /> Local Health District. <br /> Job AddresDiri <br /> ses / City ,t,�7Lot Size PM <br /> Owner's Name Address 1 ��� oZ7 7 - Phone <br /> 47 <br /> Contractor Address License No,16 Phon <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION; I SYSTEM RFPAIR ❑ OTHER ❑ / <br /> DISTANCE TO NEAREST: SEPTIC TANK .( REWER LINESZ" �- ..,, DISPOSAL FLD..,Q�>»�PROP. LINE <br /> MQ 5� <br /> FOUNDATION DAGRICULTURE 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 r <br /> Domestic/Private JK Gravel Pack ❑ Tracy Type of Casing Specifications 'ry <br /> M Public ❑ Other F1 Delta Depth of Grout Seal _ / Type of Groutaal .t c...t_. <br /> I i Irrigation _Approx. Dep [ I Eastern Surface Seal installed by � <br /> Repair Work Done ❑ Type of Pump H.P. f State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filter Material (Below 50 L� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is lfj' <br /> available within 200 feet.) Jc <br /> Installation will serve: Residence_ Commercial_--_ Other <br /> !Number of living units: Number of baidrooms � <br /> 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ZCapacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1--,' Method of Disposal <br /> Distance to nearest: Well rr Foundation 'Property Line <br /> f � r <br /> LEACHING LINE ❑ No. & Length of Iines­`,_ Total length/size <br /> FILTER BED ❑ Distance to nearest . Well Foundation Property Line <br /> SEEPAGE PITS # I Depth` Size _ Number <br /> SUMPS Ll , Distance'to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS jLl <br /> I hereby certify that I have prepared this application and that the work will be done in accof dance 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,1 shall mploy persons subject to workman's compensa- <br /> 1�tion laws of California." <br /> The appticant t cal for all required inspections. Complete_ drawing on reverse side. <br /> Signed X itle: �/ `--` Date: �� —JI-9 <br /> FOR DEPARTMENT USE ONLY G <br /> Application Accepted baya;�77. <br /> T Date 0 J ` Area <br /> Pit or Grout InspectionDate d Final Inspection by rr Date <br /> Additional Comments: cz.. —�� 4. <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6365 fl,- ►�6 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O'. Box 2009, Stk., CA 95201 + <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> s.EH 13-24/REV.t/H of 1 S J�� 180;38 <br /> EH 14-2e 1 <br />