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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �Gv�.,,f-� f 133 uhf <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA r �1 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -5'-e--e -cd.y,-+ <br /> r <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 /> rd �f?/ a J� <br /> Job Address Ci Lot Size pM <br /> a <br /> Owner's Name Address -2-26 <br /> J / Phone 83g� <br /> S Contractor e/ 2� 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 P. LINE <br /> FOUNDATION AGRICULTURE WELL ER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom eca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 4 <br /> Repair Work e ❑ Type of Pump H.P. State Work Done <br /> Well ruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> }}, available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ ether" <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 CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ ,, Method of Disposal <br /> Distance to nearest: Well ! Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines J _ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation� Property Line <br /> .45'4 <br /> SEEPAGE PiTS t C] Depth I Size Number <br /> SUMPS ❑ Distance to nearest: Well -k Foundation I 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 District. <br /> Home owner or licensed agent's signature certifies the following; "I certify that in the performance'If 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 compensati6nn'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 p4mit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m I for all required ' ctions. m_ plate drawing on reverse side. r <br /> Signed Title: ®j/fj Al[-Y Date: ZZ i <br /> I FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data �' Z Area <br /> Pit or Grout Inspection Date Final Inspection by Date��� <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manta 823-7104 ❑ Tracy 835'6385. r <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 CRECEIVED BY DATE PERMIT NO. <br /> INFO ��• ��D� g <br /> + EH 13-241REV.i/957 �IC50 `�`S/ ,ff / <br /> EH 10.28 U�--` J <br />