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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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. t ��xeAurt, <br /> Job Address City �^ �A Lot Size PM <br /> Phone —� � <br /> Owner's Name Rl oely Fs -- Address - <br /> Contractor v . Address �-� License No.496eig/ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 4%, ...DESTRUCTIO <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 /> Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 17 Public l-1 Other ❑ Delta Depth ofIbrout Seal Type of Grout <br /> —..-- <br /> I i Irrigation --Approx. Depth I I Eastern Surface Seallnstalled by <br /> Repair Work Done L1 Type Diame, <br /> ump �jlH.P. 1 State Work Done PAU ��Zxi <br /> x � <br /> Well Destruction � Well C r�=�,/alltg Material (top 50'1 _ Wz-J-4 At � � <br /> Dept � i :1il�ller Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is r <br /> available within 200 feet.) <br /> t Installation will serve: Residence_ Commercial__ Other -G <br /> j Number of living units: Number of bedrooms (' <br />' Character of soil to a depth of 3 feet: Water table depth O <br /> SEPTIC TANK C Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size Yom. V J <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth ' Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <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 Di?;tnct. <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." Contractors 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 a requir s:Complete drawing on reverse e. -, <br /> jo� <br /> Sigd X Title: Date: <br /> ne <br /> rj -FUR DEPARTMENT USE ONL <br /> Application Accepted by Date r�' ( Area <br /> R � <br /> Pit or Grout Inspection by _ � --� Data_ ­� Final Inspection by �/" Date �` <br /> I <br /> Additional Comments: V <br /> ❑ Stk 466-6781 0 Lodi 369-3621 C7 Manteca 823-7104 El 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 /> INFO <br /> FEE AMOUNT DUE ,A�M�OUNT REMITTED GASH CK RECEIVED BY DATE fjPEEjRMIT'']N}O. <br /> +.EH 1324 T REV.5 i H,' �S (� <br /> EH t4-2e �/� ` <br />