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.n APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {2091-46E8� +6V �y�7 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is.hetaby 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 j 0 VV 4�F 0? _ City !�TOG K Te of Size PM <br /> Owner's Nam _ G C f/7tO kpf297CA�ddress l`B f � Phone <br /> f..Z_ l5 <br /> Contractor__0 W fi Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Fl Public (7 Other Cl Delta Depth of Grout Seal Type of Grout <br /> -- <br /> I I Irrigation ---Approx. Depth I I Eastern Surface'Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ I <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') J <br /> Depth Filler Material IBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I I [No septic system permitted it public sewer is <br /> available within 200 feet.). <br /> Installation will serve: Residence Commercial— Other - <br /> r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> i <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to clearest: - Well__ Foundation .. Property.Line { <br /> I <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 11 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; I <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 I <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 cats required inspections. Complete drawing on reverse side. �J <br /> Signed Title: �r/( Date: <br /> I <br /> �� FOR DEPARTMENT USE ONLY <br /> Application Accepted by el Date -Z Area <br /> Pit orGroutInsfments:pection by Date Final Inspection by Date <br /> A id{'Z 1 !o ' 4 <br /> t tone � � <br /> ❑ Stk 466-6781 ❑ Lodi 369-1621 ❑ Manteca 823-7104 ❑ Tracy 835-685 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> / y FEE AMOUNT DUE AMOUNT REMITTEDO RECEIVED BY DATE PERMIT NO. <br /> INFO ) <br /> f p / I <br /> +.EH13-24{REV.1Yxsf r ! '/� J <br /> EH 14-2e (•O <br />