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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> 1 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 the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> �/Job Address n `) City �C Lot Size PM <br /> /\ <br /> Owner's Name ' Address W �No�V4-6'�4 <br /> Phone <br /> Contract �— Addre &3/ �- �C� License Phone b <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'El <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 ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing *-W <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy _ Type of Casing-, Specifications �l <br />! f'1 Public I❑ Other ❑ Delta Depth of Grout Seal Type of Grout ­ <br /> .1 1 Irrigation _Approx. Depth l I Eastern Surface Seal Installed by F <br /> Repair Work Done ❑ Type of Pump_ H.P. State Work Done_ <br /> Well Destruction ❑' Well Diameter `Sealing Material(top 501 <br /> Depth Filler Material (Below 501 <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION[.I REP,AIR/ADDITION.I;IDESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence—4'`Commercial_ Other t s <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> 1 SEPTIC TANK ElType/Mfg Capacity - No. Compartments <br /> PKG. TREATMENT PLT. ❑ '` # Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line r <br /> F <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size — Number <br /> SUMPS Ll 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 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 applica must call for all re uired ijispections. Complete drawing on reverse side. <br /> Signed Title: (.l/l�tJ�f.*--�1�-� �' Date: <br /> FOR DEPARTMENT USE ONLY <br />' Application Accepted by Brie' v ?�G� --- Date 1 -2 --Pl +Area <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> 1 Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 O 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 /> c <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 9 INFO CASH RECEIVED BY DATE PERMIT NO. <br /> e a.EH 13-24(REV.1/9 5) 171 <br /> EH 14-28 . 7 4� ' <br /> g-z(r--� ; /ala 10� 4 a_-e. We,.17 J <br />