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l APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT no <br /> Wk <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA �!,L G 1 Do <br /> Telephone (209).466-6781 Ulf LOW� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDEwnk- <br /> ��� � ' <br /> r . (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 Jo quip 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. ( /'7 '�, /-o a I) <br /> Job Address I Aa ko City o APP/►' Lot Size QM <br /> Owner's Name ZS 41, Address <br /> Contractor's Name License No. Phone 6 ff <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION X 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 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump IH.P.— State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 , <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1— <br /> available within 200 feet.) <br /> Installation will serve: Residence�, Commercial_ Other <br /> T%Number of living units: Number of bedrooms <br /> l <br /> Character of soil to a depth of 3 feet: Water table depth (� <br /> SEPTIC TANK ❑ Type/Mfg ' CapacityNo. Compartments l <br /> PKG. TREATMENT PLT. ❑ Method of Disposal C <br /> Distance to nearest: Well Foundation Property Line <br /> 6 LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation' Property.Line <br /> t <br /> k SEEPAGE PITS ❑ Depth Size Number <br /> N <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> DISPOSAL PONDS ❑ _ , ,_ „ .., - - - - . _- ., .,. ,. b <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 /> s 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." 3 <br /> lf <br /> The applicant <br /> licant mu all for all re <br /> ired inspecti S. Complete drawing r.on reverse side. G <br /> SignedY Title: _�� �� Date: v <br /> FOR PARTMENT USE ONLY <br /> Data a 0 Area +O� <br /> Application Accepted by 7, <br /> Pit or Grout Inspection by {� Date Final Inspection by Date <br /> Additional Comments: ' <br /> ❑ Stk 466781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> F <br /> FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED 8Y DATE PERMIT`-NO. <br /> INFO <br /> + EH13-24(REV.10/831 1 [ <br /> EH 1428 <br /> R <br />