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i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> li 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> "� I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6 n'� 0 "l <br /> ii (Complete in Triplicate) 04 <br /> Application is he+eby 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 IE r`t ��- 1� _ Cityv � Lot Size PM <br /> �7 5 E4 �y u -` UI" <br /> Owner's Name ri�lTlc�lGl-� �' �T��a�Idi�ddress � 'V � � Phoneq(, <br /> .. I <br /> Contractor L Address 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 t Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (' Public 1.1 Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> ] Irrigation Approx. Depth i I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 60') Jc <br /> - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIWADDITION l I DESTRUCTION 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 <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 /> l Distance to nearest: Well Foundation Property Line I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 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 <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 /> li he applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: /'' Date: <br /> 3 <br /> F. DEPARTMENT USE ONLY <br /> Application Accepted by aQ Q A A. Date Area <br /> 1= V' �� t7 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> ,Additional Comments: <br /> f.❑ 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 /> d <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK H RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +.EH i3-24(REV.riHsi <br /> EH 14-26 csU <br /> 11 <br />