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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 1 <br /> Telephone (209) 466-6781 n <br /> ` PERMIT EXPIRES 9 YEAR FROM DATE.ISSUED. <br /> (Complete in Triplicate) ;•. y <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 --� z < ��4'� City rA.)Lot Size PM <br /> Owner's Name -J - 'Address d�- y ��-�'� Phone , <br /> Contractor Address 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 WELL 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 O Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ._v_-.Approx-Depth++O Eastern F­Surface`Seal Installed by <br /> Repair Work Done ❑ Type of Pump '. 19 ., H,P. State Work Done <br /> Well Destruction ❑ Well Dia ('I, <br /> Sealing Material (top 50') <br /> : Depth I j' Filler Material.(Below 501 <br /> TYPE= OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑t DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial 1 Other € <br /> Number of living units: Numb+r of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth I <br /> SEPTIC TANK J Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest�—'Well L Foundation Property Line <br /> LEACHING LINE ❑ �No. & Length of lines ' Total length/size <br /> e <br /> FILTER BED. ❑-. `Distance to nearest: . Well { Foundation Property Line <br /> I .I j IN <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS ❑ .Distance to nearest•. WeII Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> Y~- 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 Joaquiri Local Health District. <br /> Home owner or licensed agent's signature certifies the following: '9 certify that'in the performance of the work for which this permit is issued, l shall not <br /> i employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contractirig 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." 11 <br /> The applicant must call rfor�all required inspections. Complete drawing on reverse side. <br /> Signed X TitlDate:Of <br /> FOR DEPARTMENT USE ONLY <br /> S � <br /> K <br /> Application Accepted by -0. Date LA—�— 81 Area Q <br /> Pit or Grout Inspectio Date Final Inspection bye a Datb <br /> '0' .. ....«.-w--�......: <br /> *17 <br /> Additional Comments:j �� �7?�/ - <br />; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104: Tracy 835-6385 . <br /> s Applicant- Return all copies to: Environental Health Permit/Services 1601 E. Hezelton Ave., P.O. Box 2009, Stk., CA:95201 <br /> 4 <br /> FEE AMOUNT DUE�� AMOUNT REMITTED AS RECEIVED BY DATE PERMIT'NO. <br /> INFO �• Q <br /> ♦ EH 13-24 IREV.I/fib) <br /> EH 1 <br /> 4-78 <br />