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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,' Z`,='l vO <br /> (Complete in Triplicate) �fTl,�,g0 <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 Ryles and Regulations of the San Joaquin <br /> a... <br /> Local Health District. f �� ` ' � °"4' " <br /> Job Address �G - City' Lot Size PM' <br /> Owner's Name C2.Gao-sem _ Address a – - Phdne a", (p <br /> —It <br /> �� �� QLicense no. 34�a Phon�S�`' <br /> Contractor Address t � <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 /> _ <br /> -.-FOUNDATION:—.AGRICULTURE_WELL: OTHER WELL PITS/SUMPS;:.—_ ; <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> >Gdustdal ❑ 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 /> ❑ Irrigation ---Approx. Depth fl Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump 11 H.P.���„ State Work Done <br /> Well Destruction ❑ Well Diameter r Sealing Material atop 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 /> lCommercial <br /> available within 200 feet.) SInstallation will serve: Residence_r _ Other (– <br /> Number of living units: Number'of bedrooms U) <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg j Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ' <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑--No. & Length of lines Total length/size <br /> FILTER BED 13 Distance to nearest: Well FoundationProperty Line <br /> A v <br /> SEEPAGE PITS ❑ Depth + Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line T <br /> ., <br />'DESP05AL PONDS O -- <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 /> The applic 01111 or all require inspections. Complete drawing on re se side_. <br /> Signed Title:��Q��L Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by t Data Final Inspection by Date' y <br /> Additional Comments: ` <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ 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 t� AMOUNT REMITTED CASH RECEIVED BY f. DATE PERMJT'NO. <br /> INFO L <br /> + EH 13.24(REV.t/85) <br /> EH 14-26 b <br />