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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telepholie (209) 466-6781 <br /> PERMIT EXPIRES 1 YIEAR 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. y7(J <br /> q 71 <br /> Job Address City. of Size PM <br /> Owner's Name f Address Phone t7`+ <br /> Contract ss erase No Phonegot CJ <br /> TYPE OF WEL /P P: NEW WELL L1 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> t'1 Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _..Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material Belo 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR! DITION DESTRUCTION i I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial J Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O � Method of Disp <br /> Distance to nearest: Welt Foundation--- .E Property Line I/ _ <br /> yy�y <br /> LEACHING LINE ❑ No. & Length of lines l_/ Total length/size <br /> FILTER BED ❑ Distance to nearest: Wellundation��Property Line <br /> SEEPAGE PITS 1 1, Depth 6— Size _ Number <br /> SUMPS Ll Distance to nearest: Well JA Foundation __`��dProperty 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 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 f all re s e inspections. C mplete drawing on rev e side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY p� <br /> Application Accepted byLLDate 6 Area y p <br /> Pit or Grout Inspection by Date Final Inspection by v Date 0 4 <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 /> FEE INFO AMOUNT <br /> TT777DUE AMOUNT REMITTED CAS*. RECEIVED BY ,yy DATE�1 p N <br /> PERMIT'NO. <br /> +.EH14-21(REV.i/n5] X / �rg � IEH 1A-2B L• V ( (! U <br />