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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 /> �.� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or s al the work herei�scribed. 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. f [A.114 h <br /> Job Address f[ <br /> City Lot Size <br /> PM <br /> Owner's!Name LAddress �y® �✓ �� r� 6­3 Phone <br /> Contractor's Name License No. Jos Phone .96P3_9 <br /> TYPE OF WELL/PUMP: 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 /> S ❑ Domestic/Private, ❑ Gravel Pack C1 Tracy Type of Casing Specifications Q ` <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation <br /> --Approx. Depth ❑ Eastern Surface Seal Installed by 0 <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 /> TYPE OF SEPTIC WORK: NEW INSTALLATION C4- REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> o� available within 200 feet.) <br /> Installation will serve: Residence_` Commercial Other �1 <br /> Number of living units:--I— Number of bed ro s ` <br /> Character of soil to a depth of 3 feet: ++ Water table depth , y <br /> SEPTIC TANK C3-­Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 171 Method of Disposal <br /> Distance to nearest: Well Foundation 26 Property Linea <br /> 7 <br /> LEACHING LINE N-*"No. & Length of lines 3 Total length/size <br /> Cl <br /> �--� <br /> FILTER BED Distance to nearest: Well� V Foundation Property Line <br /> SEEPAGE PITS ❑ Depth a Size r tuber <br /> SUMPS Er Distance to nearest: Well Foundation r Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 of1the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican u t call r all r wired inspections'Complete drawing on reverse side. <br /> Signed Title: 15 Zf_'� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C Date Area <br /> Pit or Grout Inspection by Date �r Final Inspection by Data / <br /> Additional Comments: <br /> t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> L z-sa(REV.1010 LIS, Co 3/ 13`gt� IRA <br /> 1� <br />