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AOr <br /> ikPPLICATION FOR PERMIT <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT 4- <br /> 1601 E. HAZELTON 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 tit ules and Regulations of the San Joaquin <br /> Local Health District. f+ l Al S I <br /> Job Address S a City Lot Size PM <br /> Owner's Name Address 62 ��'Q f� Phone Z� <br /> Contractor` Address _ : +License No. aZ9���.3 Phone <br /> TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 16-0 ✓ SEWER LINES DISPOSAL FLD.L' PROP. LINE p , <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation & Dia. of Well Casing <br /> Domestic/Private )(Gravel Pack >rTracy Type of Casing PVC Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T pe of Grout_ zt—� <br /> El Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done ^ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 Il 1 <br /> Depth Filler Material (Below 501 Z_ <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 /> 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with.San Joaquin county ordinances, state lawsr 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 Califomia."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 call for all req ui inspections. C r <br /> plate drawing on reverse side. <br /> Signed Title: Date: - '7 A-70 <br /> FOR DEP RTM T USE ONLY p <br /> Application Accepted by jlz� 7 Date ���� Area 0 <br /> Pit or Grout Inspection by Date �^ Final Inspection by Date <br /> Additional Comments: <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 RECEIVED BY DATE kPEIRIMIT'NO. <br /> INFO <br /> t EH 13-24MEV,1/85) -7<D <br /> EH 14-28 <br /> • <br />