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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 EXPIRES1 YEAR FROM-DATE ISSUEDi1 "" <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 Ryles and Regulations of the San Joaquin <br /> `Local Health District. ° <br /> W. C. �3 <br /> i� <br /> Job Address City 1 Loi Size PM <br /> l ,f .. k. <br /> . r <br /> ,-;'Owner's Name dress Phone <br /> I Contractor Address <br /> ense No. hone <br />! TYPE OF WELL/PUMP: NEW WELL ❑ 4WELL REPLACEMENT ❑ DESTRUCTI N ❑ ; <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER'LINES DISPOSAL FLD. PROP. LINE <br /> i` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ;} INTENDED USE d TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k <br /> ❑ Industrial r`❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> +"" <br /> r ❑ Domestic/Private 171Gravel Pack f Ll Tracy Type of Casing Specifications <br /> ❑ Public ,❑ Other , C1 Delta Depth of Grout Seal Type of Grout w <br /> ❑ Irrigation --Approx. Depth EJ Eastern ,c ..Surface Seal Installedby <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ 1.Well Diameter Sealing Material (top 50'1 <br /> Depth_ Filler Material [Below <br />! TYPE OF.SEPTIC WORK:: NEW INSTALLATION F-1 REPAIR/ADDITION DESTRUCTION ❑ (No-septic system permitted if public sewer is <br /> .1 available within 200 feet.) <br /> Installation will serve:y Residence a Commercial— Other r <br /> Number of living units: : Number of bedrooms — <br /> ' Character'of soil to a depth of 3 feet: Water table depth <br /> _ ye�` No.Compartmonts <br /> T SEPTIC TANK EJ Type/Mfg ` Ca <br /> _ PKG. TREATMENT PLT. ❑ r Method of Disposal 4 <br /> t• <br /> Distance <br /> to-.nearest:: <br /> We oundation Property Line <br /> r , <br /> LEACHING LINE"' LlNo!&,Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> } �. �. r..;) 4 � <br /> n <br /> i SEEPAGE PITS ❑ Depth �^ '� °i` SizeNumber <br /> SUMPS >-..❑ o Ba <br /> Distance Well Foundation l _Property Line <br /> DISPOSAL PONDS-v - <br /> I hereby certify that l 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. 0. ' <br /> i 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." t <br /> The applicant m st f I re a inspections. C m We drawing on v se side. <br /> Signed Title: Date: s <br /> FOR DEPARTMENT SE ONLY 1 <br /> Application Accepted by I l ' r `:s Date Area } <br /> 1 Pit or Grout Inspection by a Final Inspection by Date <br /> Additional Comments: <br /> F Stk 466-6781 El Lodi a.1 C7 Meco 823-7104 Tracy 835.6385 i <br /> I pplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 5201 <br /> FEE t <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> lihi+EH 1324(REV.I/a 5) !7�,/' Ig�6 :13:7 <br /> 3 $ _ <br /> EH 14-26 <br />