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+ . APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> C x (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 /> Job Address Pd-Jl City of Size PM <br /> I <br /> Owner's Name Address 0 -7 Z• �e _!S?V 2 701 <br /> ContractarA�c /C` Address �S © nse No. D Lo Phone '' <br /> TYPE OF WELL/PUMP: U NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REP;47R,0 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 /> ❑ Industrial Ll Open Bottom J Manteca Dia. of Well Excavation Dia. of Well Casing t <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specificati s k <br /> 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by t <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ -DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 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: � Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> F <br /> - LEACHING LINE ❑ No. & Length of lines Total length/size � <br /> a FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> { <br /> SEEPAGE PITS ❑ Depth Size <br /> 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 Joaquin1ocal 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."Coniractor's hiring or sub-contracting signature`` f <br /> certifies the following: "I certify that in th4 performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Cal ma." <br /> The <br /> The applic' st call for all r ire spections. Cam to drawing on rev si e. <br /> Signed Title: Date: <br /> OR DEPARTMENT US ONLY <br /> Application Accepted y <br /> Date l j9 � Area <br /> 7 <br /> . <br /> Pit or Grout Inspect b /r <br /> Y Date ( ° Final Inspection by Date <br /> Additional Comments: t <br /> ❑ Stk 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 2009, Stk., CA 95201 <br /> FEE . AMOUNT DUE AMOUNT REMITTED <br /> INFO 3 C RECEIVED BY DATE PERMIT''NO. <br /> t EH 13-24(REV.1i6 5) �/l� <br /> EH 1428 - - C�•.O J f 1p�b `. �� 7, <br />