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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T 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. L4/ / <br /> Job Address � - -- Cityf'A d'''7 'otSize PM <br /> Owner's Name Ra/07 d n F'�r Address 016 4;�Iel �y� �''e`P � Phone (\ <br /> Contractor's Name License o. on <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEK4ENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION F SYSTEM REPAIR ❑ OTHER ❑ <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 I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'Domestic/Private [KGravel Pack ❑ Tracy Type of Casing F " Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern / S rface Seal Installed by & -ell s'1 <br /> Repair Work Done ElType of Pump S H.P. / �, State Work Done <br /> Well Destruction ❑ Well Diameter ��— Sealing Material (top 50'1 <br /> Depth 125" Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 /> F <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 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 I <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 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 afifornia." <br /> The icant ust call for al?�iC omplete drawing on reverse side. <br /> Signed ' Title: (� A`�" _ Date: <br /> °n R DEPARTMENT USE ONLY <br /> Ap 'cation ccepted by Date I--Q2-R1y Area i� <br /> Pit or G Inspection r " Date Final Inspection by a�`� Date-2-2- .k7 <br /> _ Addition 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, Stk., CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT''NO. <br /> + EH 1324(REV.10183) C y <br /> EH 14-28 5. 3�O / � 7'�� <br /> i <br />