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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> ¢ 1601 E. HAZELON ON AVE., STOCKTON, CA AUG 2 9 1°$4 <br /> 'telephone (209) 466-6781 SAN JOAQUIN LOCA. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � �!�-�H DISTRICT <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. 18M for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> f� ' �= <br /> Job Address fh.i.R; L�cx•t��yy� City Loi Size � PM <br /> Owner's Address4�G• 4, Phone �U ~l- { <br /> Contractor's Name License No. f _ Phone 4a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 13' 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 f <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Z-Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i <br /> ❑ Irrigation _Approx. Depth . �❑ Eastern S rface Seal Installed by <br /> Repair Work Done ❑ Type of Pump 1 H.P. State Work Done /gam 6 <br /> Well Destruction ❑ Well Diameter SealingMaterial Itop 50'i t. r. LA <br /> Depth Filler Material (Below 501 a ! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is AFlI <br /> • , <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth Irl <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line f <br /> LEACHING LINE ❑ No. & Length of lines f Total length/size <br /> FILTER BED °— ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS - ❑ 'Depth Size Number <br /> - SUMPS F "❑ 'Distance to nearest: Well Foundation Property Line _ J, <br /> DISPOSAL PONDS ❑ <br /> 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 st c I for al d inspections. mpletep,drrawing on reverse side. <br /> Signed X �` itie: Date: 4y <br /> y <br /> F DEPARTMENT SE ONLY <br /> y <br /> Application Accepted by Date � Area <br /> Pit or Grout Inspection by Date Final Inspection by Date A02 <br /> Additional Comments: I _ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71040 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 /> FEECK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH1&24(REV.10/moi) <br /> EH 14-28 <br />