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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 EXPIRES 9 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 /> Job Address i' `r� `� �—d City Lot Size PM <br /> Owner's Name 13 LL `�G/� ��2 Address M d VZ✓� Phone d' 7 <br /> Contractor's Name ' WL -Sut License No. -� Phone <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-WEL-L• �` 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 S ftp � <br /> H.P. _ State Work Done �4GC &Iill a <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 _Jr <br /> Depth Filler Material (Below 501 1}� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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 length/size G <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> z SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL 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 /> Homeowner or licensed agen <br /> ' 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 er as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: , rY at 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 c r ired ins . Complete drawing verse side <br /> ll. ''` , > Title: Date: <br /> Bigne ��'/�• �� <br /> FOR DEPARTMENT USE ONLY 11 <br /> Application Accepted by Date � 1-2 I� Area V <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additiarial''Corflments�. F `�$i��� <br /> ❑ Stk 466 61 i"r 1 i'Dilgdi �'3 93621 © 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PE <br /> INFO RMIT`NO. <br /> + EH 13-24{REV.10183) Tko 'RIO 4559 <br /> EH 14-28 <br />