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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 TYEAR FROM DATE ISSUED <br /> � (Complete in Triplicate) z <br /> 1l YY } w1 . ,U a io1 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work �rem 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 kof,`t_h e�S-T7rl lbaquin <br /> Local Health District. <br /> 3 ­t m Size PM <br /> Job Address z City <br /> r+ � /5.� / <br /> Owner's Name Address fes.-=in e <br /> Contractor Address <br /> License No Phone �/ v7 <br /> TYPE OF WELL/PUMP: NEW WELL-O"' WELLREPLACEMENT ❑ DESTRUCTION ❑ <br /> -.,, a 1 l_ L OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRey <br /> DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES - - DISPOSAL-FLD. A' -- PROP. LINE <br /> FOUNDATION --�� AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDE15 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ kndustrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [-i Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ('l Public Cl Other ICI Delta Depth of Grout Seal Type of Grout <br /> ?r Irritgation 1 —Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done: pi!� Type of Pump ' Y H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 ! <br /> Depth Filler Mateiial(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/AD [,I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> J k �S <br /> Installation will serve: Residence— ConQercial— 'Other -- y <br /> Number of living units: Number of bedrooms Z <br /> Character of soil to a depth of 3 feet:r Water table depth 1 <br /> SEPTIC TANK ❑ Type/Mfg. Capacity_ No. Compartments <br /> PKG, TREATMENT PLT. ❑' Method of Disposal <br /> Distance,to nearest: Well Foundation Property Line <br /> LEACHING LINE El. No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance._to:nearest: Well Foundation Property Line <br /> f <br /> SEEPAGE PITS I I Depth I Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS ❑ 1 t <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 /> r rules and regulations of the San Joaquin Local Health Di'ltrict. <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 com ensa- <br /> tion laws of California." <br /> Thea Zmt call for all requi inspe ons. Co ere"drawing on reverse side. <br /> Title: Date: <br /> Signed X � , <br /> F013,,pEPARTMENT USE ONLY l <br /> Application Accepted by DateArea J - - <br /> Pit or Grout Inspection by Final Inspection by Date <br /> Q �' <br /> E � <br /> Additional Comments: <br /> 0 Stk 466-6781 © Lodi 369-3621 ❑ Manteca' 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to:',.Envi ron mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> � � r � <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERM <br /> INFO <br /> I 7:::JIT'NO. <br /> EH 13-21 IREV.t/n 51 C70 C <br /> EH 14-26 <br /> t <br />