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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) 466-67$1 . a <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.TMs 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 /> City Lot Size <br /> PM <br /> Job Address ' <br /> Addre"s Ap one <br /> Owner's Name <br /> ✓J�S�y <br /> N License No. ,COY Phone + <br /> Contractor's Name <br /> TYPE OF WELL/PUMP: NEIN WELL 7-1WELL REPLACEMENT Ll DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> .E- - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well'Excavation <br /> Dia, of Well Casing <br /> ❑ Industrial ❑ Open Bottom El Manteca <br /> i Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy A Type of Casing Type of Grout <br /> I <br /> El Public Ll Other El Delta Depth of Grout Seal YP <br /> ❑ Irrigation _--Approx. Depth ❑ 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 501 <br /> >' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION availableINo lwithin e200 feet.) if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:1 - Water table depth <br /> SEPTIC TANK ❑ Type/Mfg' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ IMethod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distanceo nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS ❑ Depth I Size Number <br /> f SUMPS ❑ Distance to nearest: Well Foundation Property Line - ' <br /> DISPOSAL PONDS ❑ 1 <br /> 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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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." f <br /> The applicant t call r, re 're inspe do C late drawing on reverse side. <br /> / itle: r.. _ _ Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY tv <br /> Date ~Z 3 "`� / Area <br /> Application Accepted by <br /> Date Fi a1 Inspection by ate <br /> Pit or Grout Inspection by <br /> Additional Comments: c <br /> ❑ Stk 466-6781 ❑ odi 369-3621 ❑ Manteca 823-7104 11Tra B35 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Seq✓ices 1 1�zeltgn Ave., P.O. Box 2009, Stls/,, C952D1 1 <br /> rC.o J` <br /> FEE MOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT NO. <br /> INFO } _ <br /> + EH 13-24(REV.10/83) �� � - �a <br /> EH 14-28 i� <br />