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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> i � <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.-.;jlir <br /> Job Address 8�© € City Lot Size PM <br /> 6 I <br /> Owner's Name Address plio� <br /> ContractorAddress / ZE6iLicense No .- Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS rkr� <br /> INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS {/ <br /> -1 Industrial ❑ Open Bottom ❑ M a Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 1-1 Gravel Pack Trac Type VPe of Casing Specifications f <br /> ❑ Public ❑ Othe ❑ Delta Depth of Grout Seal Type of Grout 4 <br /> i" <br /> ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal`Installed by <br /> Repair �DonType of Pump H.P. State Work Done <br /> �Well DWell Diameter Sealing Material (top 50'} V`. <br /> Depth Filler Material (Below 501 0;7 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EV REPAIR/ADDITION ❑:•,DESTRUCTION ❑ INo septic system permitted if public sewer is 0 ' <br /> y available within 200 feet.) <br /> Installation will serve: Residence Z Commercial_ Other r <br /> Number of living units:--/-- Number of bedrooms r <br /> Character of soil to a depth of 3 feet:'! Water table depth ' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of isposai <br /> Distance to nearest: Well ._�y b Foundation ', Property Line T 0 <br /> � t - <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to'nearest: t f­VVell'/_JQ',Q-=-Foundation 7 Property Line <br /> SEEPAGE PITS ❑ Depthize Y '" <br /> ' - Number <br /> SUMPS ❑ Distance to nearest: WellFoundation d <br /> g�— Property Line <br /> DISPOSAL PONDS ❑ I 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. F* I <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 California." .+ <br /> The applicant rpu5t call for all requir pections. Com late drawing on r erre side., 4 iif <br /> % <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Application Accepted by Area-�--- <br /> Pit or Grout Inspection by Date t f �rinlon by x - pie <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r_ <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE AMOUNT DUE AMQUNT REMITTEDCK <br /> INFO CASH RECEIVED BY DATE PERMIT''NO. <br /> ,. <br /> + EH14-24IREV.t/,a 57 '� <br /> EN 14-28 / Ca <br /> 1 <br />