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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> /Appification <br /> 1601 E. HAZELi ON AVE., STOCKTON, CATelephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin r <br /> Local Health District. <br /> Job Address 1 City � �' Lot Size PM <br /> Owner's Name - Address , <br /> Phone �21), <br /> p 9.s H1 V 9� <br /> Contractor's Name R +' License No. _ �-+ � Phone <br /> TYPE OF WELL/PUMP: NEW WEA ❑ 1 WELL REPLACEMENT ❑ DESTRUCTION El <br /> # PUMP INSTALLATION IJi 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 USI:, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ <br /> ❑ Industrial -- ❑ Open Bottom 0 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 0 Public ❑ Other ❑ Delta . Depth of Grout Seal _ Typeof Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by t <br /> Repair Work Done B Type of Pump H.P. 1V;I State Work Done 9&VaA r "I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50 –Y <br /> '1 + �I <br /> Depth Filler Material (Below 50') v! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> Installation will serve: Residence— Commercial-- Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> { Water table depth s <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 1­7Method of Disposal <br /> Distance to nearest: Well Foundation Property Line £ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <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 /> 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 uat call for all required inspections. Complete drawing on reverse side. <br /> Signed X ��rX 6 "C"'' — Title: G�, / .Date: <br /> V FOR PARTMENT USE ONLY �j <br /> Application Accepted by Date�G. J ea <br /> Pit or Grout Inspection by Date Final Inspection by 11 ` U -- Date <br /> Additional Comments: &J(✓!'X � � ✓ y� � /` _ <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <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 AMOUNT REMITTED CKIFF CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24[REV.10!631 <br /> EH 14-26 <br /> I <br />