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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 <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 /> ` j Job Address �` �^ 4Sr City rdy Lot Sizes PM <br /> Owner's Name Address A L���M ..yi;" Phone r p C] <br /> Contractor AddressO License No. Phone <br /> TYPE OF WELL/PU P: 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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 71 Public 1-1 Other Fl Delta Depth of Grout Seal Type of Grout--- <br /> i <br /> rout _I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ Q4 <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth - l Filler Material !Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is <br /> -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: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total lengtfl/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LZ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r' <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 Di§trict. <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 applican ust call for all required inspect' ns. Complete drawing on reverse side. <br /> �( Signed Title: ajhlir Date: <br /> r\ FOR DEPARTMENT USE ONLY <br /> Application Accepted by __ , Date Area <br /> Pit or Grout Inspection by Date Fina! Inspection by Date 7-i1-- <br /> Additional Comments: U , <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantec 823-7104 ❑ Tracy 635-6385 <br /> Applicant• Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK H- FiECEIV D BY DATE PERMIT'NfOO. <br /> ..EH14-24rAEV,,irs51 <br /> EH 14-28 <br />