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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON 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, <br /> Job Address - <br /> . City Lot Size , a'4-�- PM <br /> Owner's Name Z%ee- <br /> � Address t«;L, Phone��—rla <br /> Contractor's Name [.t License No. 4&0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ Phone ` <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 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 Weil Excavation <br /> El Domestic/Private Ll Gravel Pack C1 Tracy T Dia. of Well Casing <br /> ype of Casing <br /> El Public <br /> Public C1Other ❑ Delta Depth of Grout Sail <br /> ❑ Irrigation Type of Grout <br /> g ,Approx. Depth 1:1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.A. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK7 NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence commercial— Other available within 200 feet.) <br /> Number of living units:-- Number of bedrooms 3 <br /> Character of soil to a depth of 3 feet: w ' / <br /> SEPTIC TANK 1�Type/Mf I I Water table depth <br /> g Capacity!as[ T <br /> No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> 4 Method of Disposal <br /> Distance to nearest: Well P Foundation -30 Property Line 1 <br /> LEACHING LINE ! No. & Length of lines <br /> - Total length/size 1 <br /> FILTER BED ❑ Distance to nearest: Well r Foundation Pro f <br /> party Line <br /> SEEPAGE PITS Depth <br /> Size Number <br /> SUMPS El Distance to nearest: Well Foundation <br /> DISPOSAL PONDS F1Property Line <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 /> 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 California." <br /> The applicant must call for li required inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> Date: <br /> ' FOR DE ARTMENT USE ONLY <br /> Application Accepted by � � <br /> Date_ Area <br /> tAr Grout Inspection by Date Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk-466-6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 C] Tracy 635-6385-- --- -- <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 ~ <br /> INFO CASH RECEIVED BY DATE PERMIT'NO.' <br /> +EH 11241REV"10/631 <br /> EH 1426 J� S b a s <br />