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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> wa <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ;Xc2___ [ r'_. City Lot Size PM <br /> Owner's Name A ' J Address # L Phone <br /> .(- <br /> Contractor Address License N Phone —,:'VI / <br /> TYPE OF WELL/PUMP:, : NEW WELL EDWELL REPLACEMENT ❑ DESTRUCTION LJ <br /> r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL,FLD. PROP. LINE Q <br /> FOUNDATION AGRICULTURE WELL �_ OTHER WELL PITS/SUMPS L " <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other`: . ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface"tc <br /> e Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. �' F. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material [top W.) ° <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: 0 Number of bedrooms f J <br /> Character of soil to a depth of 3 feet: i Water table epth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line 1 <br /> Ya _ <br /> 1 <br /> LEACHING LINE ❑ No. & Length of fines I 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 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 applicant must call for all quir d ins ctions. Complete drawing on reverse side. I 'j <br /> Signed u r Title: Lz Date: J�` 1 <br /> f <br /> FOR DEPARTMENT USE ONLY'. <br /> Application Accepted by Date Area <br /> x <br /> Pit or Grout'Inspection by Date Final inspection by ate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 ' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIIT'NO. <br /> + EH 13-241REV.1/85) <br /> EH 1426 <br />