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APPLICATION'FOR PERMIT <br /> l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601. E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I'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 /> o. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance N <br /> Local Health District. <br /> Job Address City — Lot Size PM i <br /> Owner's Name . <br /> /�/ Address Phone ZZ <br /> Contractor 1lllltf(�S Address �4L4t!:§4ZQ License No. Phone ; <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION '❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br />' DISTANCE TO NEAREST: SEPTIC TANK !;'P_0SEWER LINES DISPOSAL FLD._6b_— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom EI Manteca Dia. of Well Excavation Dia. of Well Casing v <br /> e Type of CasingSpecifications <br /> ED Domestic/Private 171 Gravel Pack E5 Tracy yP <br /> 71 Public C1 Other 1 ❑ Delta Depth of Grout Seal Type of Grout <br /> k I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by - <br /> ' H p- State Work Done <br /> Repair Work Done E) Type of Pump <br />' Well Destruction Well Diameter Sealing Material (top 50'1 <br /> Depth ! Filler Material (Below 50'l eN <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION ( 1 DESTRUCTION t I (No septic system permitted if public sewer is <br /> available within 200 feet.) - <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( Water table depth <br /> I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total.length/size <br /> FILTER BED ❑ Distance to nearest: . Well Foundation Property Line <br /> r <br /> SEEPAGE PITS I I Depth E Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El I <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 /> II 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 California." I <br /> The applicant mustc or Ire red inspections. Complete drawing on reverse 'de. <br /> I J fs <br /> t Signed Title: Data: <br /> # FOR DEPARTMENT USE ONLY <br /> �6_ Area <br /> . � � <br /> I Application Accepted by Date - <br /> Pit or ut Inspection <br /> /by Date Final Inspection b Date 6 <br /> AdditionalC arils• v�" �'t u �/� <br /> 1 ❑ 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. Boxx 2009, Stk., CA 952/01 <br /> ,1t,///�/— 4CGD�cI[/� I" <br /> !! FEE AMOUNT DUE J AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO+ EH 13-24 IREV.i/K 5) <br /> EH 14-29 <br /> f - t' <br />