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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. ry <br /> Job Address _ ���� / 7 Lcy City p c Lot Size�'� C PM <br /> Owner's Name M A g5Address 1 y 73 ? /�l;,DLPhone <br /> Contractor's Name •�� FCJLG�P- License No. —g Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMR.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well.Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl,Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —L—Approx. Depth".. ❑ Eastern Surface,Seal Installed by <br /> Repair Work Done ❑ Type of Pump " H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material it op 501 <br /> Depth Filler Material /Below 501 - J <br /> TYPE'OF'SEPTIC"WORK: NEW INSTALLATION'A REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> �;;,,A. r .,, —available-within 200-feet.). .. "..w Installation will serve: Residence Commercialther <br /> Number of living units: ___ Number of bedrooms <br /> � <br /> Character of soil to a depth of 3 feet: A 3� Water table depth � cry <br /> s 111 <br /> SEPTIC TANK ❑ Type/Mfg P, �/_I Capacity « No. Compartments <br /> PKG. TREATMENT PLT.;❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line fid ;"7� <br /> LEACHING LINE ; No. & Length of lines " ,qb '�" Total length/size "7(f> <br /> FILTER BED i Distance to nearest: Well. ^ Foundation Property Line �6 F`✓~' <br /> SEEPAGE PITS i❑ Depth Size Number <br /> SUMPS {❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El <br /> I hereby certify that I have prepared this application and that the wdik­will;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 foilowing:-"l-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 per ormance"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 calll f all required inspections. Complete drawing on reverse side. <br /> Signed X z� r ,�� _ Title: Date: <br /> { FOR DEPARTMENT USE ONLY <br /> Application Accepted by' _ Date r � Area <br /> Pit or Grout Inspection by Date Fina1)ns ction by Date-2-/1-0:5 <br /> Additional Comments: ( S 01 /� ANO <br /> ❑ 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 95241 <br /> ,t <br /> t` FEEAMOUNT DUE AMOUNT,REMITTED ° CK#- , + RECEIVED.BY DATE PERMIT`NO. <br /> INFO- <br /> .. -CASH -" - / -- <br /> + EH 13.24[REV. <br /> s ..+;EH 1428 _ <br />