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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA � .� rf� , � <br /> Telephone (209) 466-6781 /,QO <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED11 <br /> 19 <br /> N <br /> (Complete in Triplicate) 10 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install the work herein descnYeld-' plication 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 o Khe Sian Joaquin <br /> Local Health District. <br /> Job Address �~ tl �"►"� �,/ City—rk-z l-0 Lot Size PM <br /> Owner's Name/ <br /> ' Xi AddressA l/ 1, �i td�. Phone ! f- -A t J y <br /> Contractor � �^4-r ` Address ��^� f 6i 'X - license No. l "r1 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 Dia. of Well Casing <br /> LkDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public 17 Other ❑ Delta Depth of Grout Seal Type of Grout-_-- <br /> I <br /> rout _I I irrigation ­Approx. Depth l I Eastern Surface Seal Installed by I - p <br /> Repair Work Done Type of Pump /.� H.P. State Work Done <br /> Well Destruction ❑ Well Diameter � Sealing Material flop 50'I _����-�<E-! *k<..tSa _r.•. ��. hf'L' iX� v�.) <br /> Depth - 1 � ^► Filler Material (Below 501 — a <br /> TYPE OF SEPTIC WORK: NFW INSTALLATION I 1 REPAIR/ADDITION I ) DESTRUCTION I I INo 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 s <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 Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of-lines Total length/size r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size _ Number <br /> SUMPS E_I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ _ <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."Contractors hiring or sub-contracting signature <br /> certifies the fallowing:"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 /> Theapplicant mustcallfor all required inspections. Complete drawing on reverse Sid j] / <br /> Si ned X n 1, +7 , � �•! �" - Title: Data- - <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date 4Area <br /> Pit or Grout Inspection by Date Final Inspection <br /> Additional Comments: <br /> ❑ 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. Box 2009, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. <br /> INFO <br /> t EH 13-24(REV.a/n toLi <br /> EH 14-28 C3 J �--t9 �� 47 'D '�.3 S <br />