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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 n <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> +F (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 Saa.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. 41 41 <br /> T;� t Q�. <br /> � �i�,. City Lot Size O. P � s��i <br /> Job Address - <br /> Owner's Name �/s � C 'Address - Phone <br /> 40 <br /> Contractor <br /> / f Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT ElDESTRUCTION Ll <br /> _—PUMP INSTALLATION ❑ — " SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia..of"Well*Excavation" ' R Dia. of Well Casing <br /> ❑ Domestic/Private_ , ❑ Gravel Pack ❑ Tracy Type of Casing }* Specifications <br /> ❑ Public [],Other ❑ 0e1ta J Depth of GroutSeal ' r�` Type of Grout <br /> ❑ Irrigation _Approx. Depth Q Eastern Surface Seal Installed by--" <br /> Repair Work Done ❑ 'Type of Pump H.P. �`_ S tate Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top,'50') >� <br /> 'k <br /> Depth Filler Material (Below.50s)` <br /> TYPE OF SEPTIC_WORK:. NEW INSTALLATION ❑ REPAIR/ADDITION H ' DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> t t available within 200 feet.) (��{ <br /> Installation will serve: Residence Commercial Ott her b t V` <br /> Number of living units. Number of bedrooms <br /> Character of soil to a depth of 3 feet:P '' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg - Capacity-_-_ t l— No. Compartments <br /> PKG. TREATMENT PLT. ❑ " Method of:Disposal <br /> Distance to nearest: Well - - Foundation Property Line <br /> E ' ` r Total length/size <br /> LEACHING LINE ❑ No. & Length of lines„ - g, <br /> FILTER BED O Distance'to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size .. Number <br /> SUMPS t ❑ Distance to nearest:_ Well Foundation Pioperty Line <br /> 1. <br /> I DISPOSAL PONDS ❑ � F. } <br /> s •. <br /> I 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 /> 4 ruies and regulation s of the San Joaquin Local Healtti District. i <br /> Home owner'or licensed agent's signature c'eitifies 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'af 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 15 issued;I`sWall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican st all for all required inspec` ns. Complete drawing on reverse side. <br /> Signed Title: —la.,2 ,i- Date: G' <br /> y� R DEPARTMENT USE ONLY � ,—�� <br /> Application Accepted by ! Date' a <br /> Pit or Grout Inspection by DateFinal inspection by L-.� Date <br /> 16 <br /> Additional Comments: <br /> I ❑ <br /> ❑ Stk 466-6761 ❑ <br /> Lodi-.369 3621 Manteca 823-7104 LJ 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 /> IFEE NFO AMOUNT-DUE! ^AMOUNT REMITTED G SH " RECEIVED'BY DATE PERMIT NO. <br /> i <br /> y 5� r► ��,- <br /> + EH 13-241REV.I/nsl 7,0s�� s _ <br /> EH W28 _. - <br />