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A 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 /> (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 /> 00 <br /> Job Address w City rl= Lot Size PM <br /> 4 <br /> Owner's Name Address Phon <br /> tt r <br /> Contractor dtlress License No.4y%2 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ­."';WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER Ll <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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> AgiOof'JDmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public f Other f:E Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation —Approx. Depth I ) Eastern urface Seal Installed by _ <br /> Repair Work DoneType of Pump H.P. State Work Doner <br /> I Ir <br /> I <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 FMP <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF-SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION l I Wo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other -,y + <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 G i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property"Line <br /> SEEPAGE PITS l I Depth Size Number <br /> z .--r--Dist __s em �,.i',�.-,�-�.,. -.�. „ <br /> "SUMPS'�T ❑ Distartice to nearest: Well' Foundation Property Line <br /> DISPOSAL PONDS ❑ G <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 Y i <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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." r <br /> The applicant mus all for all required inspections. Complete drawing onreverseside. <br /> Signed X Z Title: Date: L' k <br /> F R DEPARTMENT USE ONLY <br /> ` vj � <br /> Application Accepted by Date S~ O Araa K2 <br /> Pit or Grout Inspection by ate Final Inspection by Date �v <br /> Additional Comments: <br /> I <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 ^CK RECEIVED BY DATE PERMiT'NO. <br /> INFO CASH <br /> + EH 13-24 MEV.1/ 51 <br /> EH 14-26 - ��/4 0 o t <br />