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APPL!-fATI6A 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. EJ�/� J S <br /> Job Address `� �� E, t ` DSS �t/t" City `-' '` Lot Size PM <br /> � w r`c e S 'w. Zo fi �� °l szal <br /> Owner's Name S � Address v �• �'�t� � ' � Phone 21U9 <br /> Contractor F i[cW'CA1, i VIL Address `tl�7v15 r UE License No. `�f Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER, N �,A <br /> , <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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ 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 501 <br /> Depth Filler Material (Below 501 <br /> PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic syste miffed if public sewer is <br /> available 200 feet.) <br /> Installa will serve: Residence— Commercial_ Other <br /> Number of live nits: Number of bedrooms <br /> �k <br /> Character of soil to a of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Ty fg pacify No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to neare We Foundation Property tine <br /> LEACHING LINE ❑ No. & Lengt ines Total length/size <br /> FILTER SED ❑ Di s to nearest: Well undation Property Line <br /> SEEPAGE PITS ❑ Depth Size umber <br /> SUMPS ❑ Distance to nearest: Well Foundation erty Line <br /> SAL 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 California." <br /> The applicant must call for all required Iin`sp-ections. Complete drawing on reverse side. l l <br /> Signed la"Pand u�l �-� O" Title: S'�'''�r°`- P t4", G is 1-Date: f 2'I 3` 06 <br /> P NT USE ONLY 'r <br /> Application AcceptedDate Area <br /> Pit or Grout Ins do y Date 8 Final Inspection by Date s <br /> Additional Comments: —k- <br /> ,NdStk 466-6781 ❑ Lodi -3621 ❑ M eco -71 Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 <br /> allMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'N0. <br /> EH 13-24 MEV. w 1 <br />