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APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone Q09j 466-6781 t <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 descYibed.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the-Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address V C\\�� City Lot Size PM i <br /> Owner's Namely 11 y r Address Phone <br /> k Contractor <br /> Add res C� ' License No. Phone� E <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ _ SYSTEM REPAIR C1 OTHER ❑ l <br /> DISTANCE TO NEAREST: SEPTIC TANK I '"SEWER LINES DISPOSAL FLD. PROP. LIN ' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIO alJ ! <br /> ❑ Industrial ❑ Open Bottom.,,,: ❑ MantecaDia. of Well Excavation Dia. of Well Casing h. <br /> - ❑ Domestic/Private, �. Gravel JPack ❑ Tracy,,. Type of Casing Specifications' <br /> ❑ Public LJ Other El Delta' Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal'Installed by <br /> Repair Work Done ❑ Type of Pump r H,P. State Work Done <br /> Well Destruction ❑ Well Diameter. -1 Sealing Material (top 501 <br /> fi` likz; � Depth Filler Material IBelow 50') t <br /> TYPE OF SERDC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within.200 feet.) 'v <br /> Installs ill sere: Residence_ Commercial_ Other i <br /> Number of living Number of bedrooms j <br /> Character of soil to a de t feet: <br /> p ater table depth t <br /> SEPTIC TANK ❑ TV. <br /> g Ca No. Compartments, <br /> PKG. TREATMENT PLT- ❑ Method of Disposal <br /> Distance to nearest: Foundation Property Line <br /> r <br /> LE�Hl LINE ❑ Length of lines Total length/size <br /> :r FILD ❑ Distance to nearest: Well Foundation roperty Line <br /> SEEPAGE PITS ElDepth Size Number <br /> SUMPS ❑ ,Distance to nearest: - Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t , <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 /> emplo any person in su manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ' <br /> certifie a following:""I rtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- k <br /> 'I tion la11 <br /> o California." i <br /> The app Iust call for II required i knetions. Complete drawinon re <br /> � <br /> verse side. <br /> , <br /> Signed Title: Date: ' <br /> i <br /> F T T N <br /> r - <br /> Application AccPnts; <br /> Date — Area <br /> I Pit or Grout InsDate r: Final inspection by Date �Z <br /> Additional Com <br /> ❑ Stk W66-6781 ❑ Lodi 369-362111 L] Manteca 823-7104 ❑ Tracy 8355-6385 ' <br /> Applicant'- Return all copies to: Environmental Health Permit/Services'1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTEDrCKH RECEIVED BY DATE PERMIT"NO�EH 13-24 ri <br /> + EK 1428IREV.1/65l �5 C t <br />