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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> 1601 E. HAZEL 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 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 /> �o <br /> 2 3 2 +VCity — oh' <br /> Job Address r Y'ot size PM <br /> e MPhone <br /> Owner's Nam �'�" Address PhonContractors/M `- 0��v ddLicense NoQ�6 <br /> x <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEMENT ❑ DESTRU TION ❑ <br /> Ekt PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ifr x t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> � 1 <br /> j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ¢ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (� Public n Other Ll Delta Depth of Grout Seal Type of Grout - n <br /> I'I Irrigation --Approx. Depth. 11 stern S rfay -3eal installed by <br /> Repair Work done ❑ Type of Pump H.P. State:Work Done VAI <br /> Well Destruction ❑ Well Diameter M�Seaiing WiFrial'Itap 50'I— <br /> Depth- Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION I ) INo septic system permitted if public sewer is <br /> t available within 200 feet.)-, <br /> Installation will serve: Residence #� Commercial— Other a f <br /> Number of living units: Number of bedrooms #4 3 1 <br /> Character of soil to a depth of 3'feet:' Water able depiht <br /> SEPTIC-,TANK ❑ Type/Mfg Capacity "_1\16 Cornpart&nts t <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance trq nearest: Well Foundation PropertyLine <br /> LEACHING LINE ❑ No. & Length of lines I Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Four)dation Property Line i <br /> SEEPAGE PITS i I Depth Size f Number € <br /> SUMPS Ll Distance to nearest: -Well Foundation Property Line <br /> DISPOS NDS ❑ I <br /> I hereb certify that I have prepared this application and that the work will be tlone in accordance with San Joaquin county ordinances, state laws, and <br /> rules a regula ions of San Joaquin Local Health Diltrict. <br /> Home o ner or icense a nt'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 a per n in su in r as to be me subj t to workman's comperfsation-.laws of.California.'. Contractor's hiring or sub-contracting signature <br /> certifies the wing: "I c fy at in Orman f the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion law ifornia." - ;! <br /> The ap ican al a in s. C plate drawin <br /> r- Y <br /> SignedrX Title: Date <br /> FOR PARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> j .4 <br /> Pit or Grout Inspection by Date v Final Inspection by �� Dat <br /> Additional Comments: <br /> ❑ Stk J 466-6781 ❑ 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 200, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. <br /> INFO �j CASH <br /> �.EH 13-24 MEV_.1 _ � <br /> EH 14-26 ✓✓ 1 r <br /> } <br />