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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 DistAct. is <br /> Job Addre ^ Ci Lot Size PM <br /> ss tY <br /> Owner's Name L;J Address i '� Phone <br /> Contracttl% 1 y �C/m �(�,Address&&V4 10i License NO.?_V .0__V_Phoney 3 �� <br /> TYPE OF WELL/PUMP: NEIN WELL y <br /> ❑ WELL REPLACEMENT ElDESTRUCTION ❑ <br /> PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER ❑DISTANCE T0.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 /> ❑ ndustrial—­­❑ Open Bottom.-------0 Manteca - Dia. of Welf Excavation" °–b'ia. of Well Casing <br /> i <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy ,.a Type of Casing Specifications <br /> Public ❑ Other ❑ Deltak t Depth of Grout Seal Type of Grout i <br /> ❑ Irrigation ---Approx. De ❑ Eastern, Surface Seal Installed by <br /> Repair Work Done ED Type of Pump H.P. State Work Done s <br /> Well Destruction ❑ Well Diameter Sealing Material•{top 501 <br /> Depth Filler Material {Below 501 <br /> YPE OF SEPTIC WORK: NEW INSTALLATION ❑ REP,AlR/ADDITIONfC] DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> - _ available within 200 feet.) ' <br /> 4 <br /> Installation Residence—4;Commercial_ Other G <br /> Number-of living.units: "her of bedrooms J <br /> living.u :. <br /> Character of soil to a depth of 3 feet: '-�' Water table depth G <br /> f 6 s <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: Well Foundation Property. Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth f Size Number ! s <br /> }.i <br /> SUMPS ❑ Distance to nearest: Well Foundation. Property Line , v ' <br /> DISPOSAL PONDS ❑ I f <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 C ornia." <br /> The applic t ust call for all required i1; ions. mplate drawing on arse side. <br /> Signed Title: Da <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date /–�/ Area <br /> r <br /> Pit or Grout Inspection by Date Final Inspection by Date Il-16-rel <br /> Additional Comments: – <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 95201 <br /> T <br /> FEE AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT'NO. <br /> INFO { <br /> + EH 13-241REV.1/8ril ' <br /> EH 1429 <br />� Y <br />