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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 /> Job Address L7at �� � <br /> City Lot Size pM <br /> Owner's Name Address /1 Cl G o <br /> �j Phone (OV o 0 <br /> ContracZLI Pl Address t•� ` <br /> b� _License No_ �S Z'Z(o Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 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 <br /> ❑ Domestic/Private ❑ Gravel Pack 'p Tracy- T Dia. of Well Casing <br /> ype of Casing Specifications <br /> El Public ❑Other x r ❑ Delta Depth of Grout Seal <br /> ElIrrigation _A Type of Grout <br /> pprox_.Depth ElEastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction ❑ Well DiameterState Work Done <br /> Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial_ Other available within 200 feet.) <br /> Number of living units: --/— Number of roo s_ — <br /> Character of soil to a depth of 3 feet: / <br /> SEPTIC: TANK Water table depth �o <br /> Lr�Type/Mfg tments <br /> o� <br /> PKG. TREATMENT PLT. E3Capacity Z(y40 No. Compar <br /> ` <br /> Method of Disposal <br /> Distance to nearest: Well �Jro— Foundation r� Property Line 40(5 f <br /> LEACHING LINE - 2r--No. & Length of lines .� —�+ aQ <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Z60 Foundation os' Property Line 2d + <br /> SEEPAGE PITS P' DepthSi 3 Number , <br /> SUMPS ❑ Distance to nearest: Well 0' Foundationd <br /> DISPOSAL PONDS F1 --Z�— Property Line d <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, 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 c_ampensa- <br /> tion laws of California.,, ' <br /> The applicant m call for I re ired inspections. Complete drawing on revrer� ide. <br /> Signed , Title: v[ O g� <br /> _ _ _ _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 10 <br /> Date <br /> I v 1rJ Area v <br /> Pit or Grout Inspection by date Fi�Inw�tbn by j <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 y <br /> ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 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 gMOUNt DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE EPERMIT'NO. <br /> EH 13-24+ EH 1428(REV.1/a5) O ` G <br />