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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR 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. �R O 3 6' <br /> fj�ziqX a a— / city07A Lot Size PM <br /> Job Address ' � <br /> Owner's Name 151,444"$Z it�o r� Address '�f"t Phone <br /> Contractor 0 r o T Address _�Ay, License No. .r Phone Z��` I <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 I <br /> A <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ISN <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> {l Public ❑ Other P Delta Depth of Grout Seal Type of Grout <br /> I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION i I (No septic system permitted it public sewle <br /> aV lable within 200 fee 1 p yj f� <br /> Installation;will serve: Residence K Commercial_ Other E//�/�� �?10 <br /> Number.of.living units: Number of bedrooms �.� �Lw �rrg 7`�W1 <br /> Character of soil to a depth of 3 feet: Water table depth f `- <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Property Distance to nearest: Well Foundation Pty Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 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 Califo nia." <br /> The applic err call for II requir in pec' s. mplete drawing o averse sid <br /> Q` <br /> Signed X Title: 1.� Date: / �� V <br /> FOR DEPARTMENT USE ONLY 'f <br /> Application Accepted by Date J ` Area <br /> Pit or Grout Inspection by Data Final Inspection by Date 7 <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 /> EE <br /> INFO AMOUNT DUE AMOUNT REMITTED ASCK H RECEIVED BY DATE PERMIT'NO. <br /> O <br /> ♦ EH13-24IREV.i/x5) ­_ <br /> EH 14-26 <br />