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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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. <br /> Job Address I CityLot Size PM <br /> Owner's Name 1 1 t SS16 4!d _ Address �W4 ' Phone <br /> ContractortikkcAddress ZLW License No. )l Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR!!�'J OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial D Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑,,,Domestic/Private 171 Gravel Pack LJ Tracy Type of Casing Specifications <br /> ee).KlRublic f_l Other f 1 Delta Depth of Grout Seal Type of Grout <br /> ! I 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 ❑' <br /> Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> I'1� 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 /> Distance to nearest` W611 Foundation . Property Line <br /> LEACHING LINE D No. & Length of lines —- Total length/size <br /> FILTER BED D Distance to nearest: Well ti ,Foundat on Property Line Q <br /> SEEPAGE PITC--A :[,I :Dppth _y/ Sze 1f �/ Number <br /> SUMPS r Cl��O'istance to- err est: We Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that Lhave prepared this application and tF t the work will be done in accordance with SA-Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health D1 trict. <br /> Horrie owner or licensed agent's signature certifies tt4following: VI ceNify-that in the performance,of the work for Which this permit is issued, I shall not <br /> employ any person'in such manner Is to become subject to workman's compernsation taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the�ormance of t�worlafor which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws`ofCaiffomia:" <br /> The applicant uired " -Complete drawing on reversesi <br /> Signed X <br /> Date: <br /> DEPARTMENT USE ONL <br /> Application Accepted by DateArea -.126 <br /> Pit or Grout Inspection byDate Final Inspection by Date —Z3'�s� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621' ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to:'tnvironnr ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> YFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> ♦ EH 13-24(REV.1/0 51 <br /> a <br /> EH -2I} <br />