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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA i <br /> Telephone (209) 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 welU pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address � � — City J�-d- _ Lot Size PM <br /> Phone <br /> Owner's Name > � Address <br /> Contractli � )^ -` Addsessf) lrr. mss - - `7 License No.7"���' s r Phoned <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 /> CkDOmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> [`!.Public ❑ Other « F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation �_.Approxi Depth I I Eastern Surface Seal Installed by. - - <br /> Repair Work Done Cliit- Type of Pump =.9*c.+ H.P. State Work one <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 - <br /> Depth Filler Material IBelow 50� O <br /> TYPE OF SEPTIC WORK:-- NEW INSTALLATION I.] REFAIR/ADDI_T_ION 1,1 . DESTRUCTION 11T1No septic system permitted if public sewer is r1 <br /> available within 200 feet.) <br /> Installation will serve_ Residence Commercial_ Other Ul <br /> Number of living units: Number of bedrooms r <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. ❑ f Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED El Distance Ito nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1�-D pih4 : Size--� Number <br /> t <br /> SUMPS C-1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and 11 at-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 Di1trict. '^• i - <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 /> The applica r all re Complete drawing on reverse side. } <br /> Signed X ' Title: q-r n1 Date: ! t <br /> : FO DEPARTMENT USE ONLY <br /> Application Accepted by Date Area— <br /> A <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 0 CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO y <br /> + EH 13.21 tREV.1/n 5) <br /> EH 11-26 <br />