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I 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 7 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 SaCounty Ord' a IN for sewage or No. 1862 forwell/pump and the Rules and Regulations of the San Joaquin <br />{ Local Health District. ut�.o Pf�'t''m S <br /> a�- Wr'�i ' <br /> Job Address C <br /> I r. City Lot Size <br /> PM :5 <br /> .. Address 9'Lt (jr1 r glaia <br /> 44 <br /> Owner's Name t��� ��. �tQir, phone <br />` Contractor's Name 4.lo i <br /> ' <br /> 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 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; El Tracy Type of Casing Specifications <br /> ❑ Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation <br /> ---Approx.,Depth Eastern S rface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P._/ ! State W rk Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> r i � 1 <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_ Other E <br /> Number of living units: Number of bedrooms ` <br /> Character of soil to a depth of 3 feet: <br /> 'Waterrtable depth <br /> SEPTIC TANK ❑_ Type/Mfg -Capacity , No. Compartments <br /> y <br /> PKG. TREATMENT PLT. ❑ ~Method of Disposal <br /> Distance to nearest: Well Foundation Property Line U <br /> LEACHING LINE ❑ No. & Length of lines t Total length/size <br /> FILTER BED 17 Distance to nearest: Well Foundation Property Line T <br /> SEEPAGE PITS ❑ Depth !I Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ; <br /> 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 /> Y � r <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 wr- <br /> rork for this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." • - Y. --..1 4 <br /> The applicant m st tali for II required inspections. Complete drawing on re arse side. <br /> Signed ,• Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area-1/3— <br /> Pit <br /> rea ?Pit or Grout Inspection by Date Final Inspection by ' Date gs <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63% -- <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 r AMOUNT REMITTED C RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> 4 Y ' <br /> * EH W26 1REV,10/631 LiS` TV s 5 --a LI <br />