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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT y <br /> 1601 E. HAZEL T ON 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. <br /> C� r <br /> ,Job Address Ci JOG�T %f�1 Z C)tY�J Lot Size " f I PM <br /> Owner's Name — Address <br /> Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP: License No, Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial If Open <br /> Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Weff Casing <br /> Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> El Irrigation Type of Grout <br /> _A <br /> pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H P <br /> Well Destruction E3 Well Diameter State Work bone <br /> Sealing Material trop 50'1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 171TIO <br /> REPAIR/ADDIN ❑ DESTRUCTION <br /> (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial vailabie within 200 feet.) <br /> Other <br /> Number of living units: Number of bedrooms J gyl�,-Z- ACT 09, L <br /> Character of soil to a depth of 3 feet: 7 , <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ CapacityNo. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines 1 <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS Number _ <br /> ❑ Distance to nearest: Well Y 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 following: "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 jmust call for all fr d inspect' Complete drawing-on reverse side. <br /> XSigned X ( ;1r �s] -`� Title: <br /> Dat.: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date 3�[0�� Q <br /> _. Area <br /> Pit or Grout Inspection by � Data Final Inspection by <br /> Date ' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 12b <br /> c M1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,�P.O. Box 20Og S k. CA 95201 �"_ ! <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO C RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.1/ 51 <br /> EH 1428 <br />