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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> d 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 6 unty Q finance .549 fir sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. I A <br /> Job Addr. s 4� City 04 "'MJ57 Lot Size PM <br /> ,45i �� f <br /> Own. s Name Address ��28I�yt Phone <br /> ` t <br /> Contracto _Addres ` .Lvr - a icense- iA3 Phone CwY/ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP ACEMENT ❑ DESTRUCTION <br /> PUMP"INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> I 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 /> Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public [1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.-Approx. Depth l l Eastern Surface Seal Installed by - r <br /> Repair Work Done ❑ Type of Pump ` H.P. State Work Done <br /> Well Destruction Well Diameter 2 ' Sealing Material (top 50') f1P7A=_ <br /> Depth Filler Material Welow 50'1 - k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I I DESTRUCTION ( 6 (No septic system permitted if public sewer is i <br /> '* "_"available within 200•feet1 <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms �„ r <br /> r <br /> Character of soil to a depth of 3 feet: s Water table depth - <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> f <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 4no <br /> FILTER BED: ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ NumberSUMPS L-1 'Distance to nearest: WeII 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 larules and regulations of the San Joaquin Local Health DiWict. <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 <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 st c I for all re" fired 'nspections. Complete drawing on raver side- <br /> 7- 17 <br /> Signed X ' "�-/ Title: A /� Date: <br /> FOR E; <br /> A- <br /> USE ONLY � <br /> r.�r.�..'r`.+i ,WART <br /> Y P <br /> Application Accepted by Date r� Area <br /> Pit or Grout Inspection by Date Final Inspection b Dat <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 ,` <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f <br /> 69 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> a EH 13.24(REV.I/H 5) ���! <br /> EH 14-26 4 .- - / <br />