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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON 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 _ / S Ci Lot Size PM <br /> Owner's Name '-z Address 9, y Phone 2 Q& <br /> 67 <br /> Contractor's Name �.�u`a"R / "� - License No. Z/s Phone <br /> TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD., PROP. LINE <br /> r <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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigatiarn ---Approx. Depth ❑ Eastern Surface Seal Installed by � <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done LV <br /> Well Destruction ❑ ` Well Diameter Sealing Material (top 50') <br /> I ° Depth - Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONX DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available withim2OO feet.) <br /> Installation will serve: R dence_ Commercial— Other m �* <br /> Number of living units: Number of be ooms Z�� �. ! I" f <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 ofCDisgosal <br /> Distance to nearest: Well �t/� Foundation_ Property Line <br /> LEACHING LINEI No. & Length of lines 2- O Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation -__ operty-Line <br /> SEEPAGE PITS Depth SizNumber c)A.)r- <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r <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 compensa- <br /> tion laws of California." <br /> The applicanm t <br /> K, 713PIfk dinspections. Complete drawing on reverse side <br /> Signed X Title: Date: <br /> t ­-IFOR'DEPARTMENT USE ONLY "� Q <br /> Application Accepted by el Date 97 6 Area ©) <br /> Pit or Grout Inspection b Date Final Inspection byDate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY LDATE PERMIT`NO. <br /> +EH 1324(REV.10l83) <br /> EH 1426 <br /> r <br />