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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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. <br /> Job Address _d-fA,'� �- City - ,� ,.,�_LotSize yQf PM <br /> Owner's Nam el 1f0Y'Y� Address/,�U�a( NF� ` � �'"!" Ad Phone "2 ffr <br /> A�j � 2Y2 � <br /> Contractor's Nam C License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 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 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout- <br /> 11 <br /> rout❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P. _ _ State Work Done if✓ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material IBelow 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 I <br /> Number of living units: Number of Pdrooms <br /> Character of soil to-a depth of 3 feet: /7�a.�iiry Water table depth <br /> SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments ") <br /> PKG. TREATMENT PLT. ❑ 4 Method of Disposal <br /> Distance to noarest: Well Foundation Property Line <br /> LEACHING LINE a No. & Length of lines 410 '' dotal length/size <br /> FILTER BED El Distance to clearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Number t <br /> SUMPS I-- e Distance to'nearest: Well Foundation 16 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."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 toworkman's compensa- <br /> tion laws of California." <br /> The applicant must call f r all required inspections. Complete drawing on revers side. <br /> %Signed Title: ?f Date: <br /> FOR DEPARTMENT USE ONLY ,,��jj,,� <br /> Application Accepted by Date r�' f 46 Area la <br /> Pit or Grout Inspection by Date Final Inspection by n DSS <br /> Irr/ <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, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT''NO. <br /> INFO CASH <br /> + IEH 13-24 EH 14-28(RM 10/81 <br /> i <br />