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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-Ml <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 O l 4,1 !D1 Aa:1 2 City /t'4 rim C5!, Lot Size �T�G PM <br /> Owner's Name 12&gi✓ o r✓ Address U Phone <br /> Contractor r ��CJN�ddress License No. hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r A <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 /> El Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout- <br /> El Irrigation --Approx. Depth ❑ 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 50') <br /> Depth Filler Material (Below 501 <br /> TYPE. OF SEPTIC WORK: NEW INSTALLATIONS REPAIR/ADDITION ESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_��Commercial_ Other u <br /> Number of living units:�_ Number of bedrooms�— <br /> Character of soil tc a d pe th of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ , Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> a <br /> LEACHING LINE %L,'No. & Length of lines. ��.Tootta�l-lle-ngth/size <br /> FILTER BED El Distance to nearest: Well .-_foundation s Property Line P ?!571_47__ <br /> SEEPAGE PITS ❑ Depth Size le Number <br /> SUMPS ❑ Distance to nearest: Welt 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 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 fallowing: "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 required inspections. Complete drawing on reverse side. r7 <br /> Signed X rI Tiff6:. Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byV YX/t��`���� Date r r47 Area <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> -L"- <br /> � <br /> Additional Comments: <br /> ❑ Sik 466-Ml ❑ 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 /> RE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 113-24{REv.1 est /��:... ��/lam" � ._ .•,..., <br /> EH 114-29 I <br />