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APPLICATION,FOR PERMIT <br /> Y � <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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. O r r. <br /> , e9a► � . City PM <br /> Job Address � � of Size . <br /> -8 onv <br /> Owner's Narffe'� Addrea Phone <br /> Contractor's Nam � �'�''icense 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 /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications „ <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ 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 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION ElDESTRUCTION El (No septic system permitted if public sewer is 3) <br /> " available within 200 feet.) <br /> Installation will serve: Residence ACOM me ial_ Other <br /> Number of living units: Number of bedrooms <br /> r <br /> Character of soil to a depth of 3 feet: Water table depth <br />' SEPTIC TANK ❑ Type/Mfg w Capacity No. Compartments Z� <br /> PKG. TREATMENT PLT. El Method of DisVsal <br /> ?Distance to nearest: Well Foundation Property Line . <br /> ` r Total len th/size <br /> LEACHING LINE ,�'No. & Length of lines g <br /> FILTER BED ❑ Distance to nearest: Well— Foundation _ Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well 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 /> =s 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:"l 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 app422gLmust calif required inspections. Complete drawing on reevverse.side. } <br /> Signed X i' �� v�9��J!" Title: �/' •c� rd — Date: —% F <br /> FOR D ARTMENT USE ONLY <br /> Application Accepted byDateArea <br /> Pit or Grout In by Date Final Inspection by / 0ate��� <br /> o <br /> Additional Comments. <br /> ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. <br /> INFOl [� <br /> + EH 1324(REV.101831 <br /> 11-79a.—I �'Z- �/ '�� " J-E�-Ji _ %9 <br /> EH 14-M - .. .- <br />