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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .i. 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i <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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size PM <br /> Owner's Name t-/% 1�17,V Address ��� /� �/"�— Phone <br /> Contractor 4WQ"/.J S $3X_3 Address 1 License No. 97 Phone <br /> TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ r <br /> DISTANCE TO NEAREST: SEPTIC TANK —� SEWER LINES DISPOSAL FLD. ,-- PROP. LINE f <br /> FOUNDATION ,F�� AGRICULTURE WELL„_ OTHER WELL-MA-49'.__ 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 /> �omestic/Private Gravel Pack ❑ Tracy Type of Casing ..-__ Specifications <br /> 1-1 Public ❑ Other Cl Delta Depth of Grout Seal _ h1_ Type of Grout �r�t <br /> I I Irrigation �Approx. Depth I I Eastern Surface Seal Installed by f1!'flt1 '.1 _Y t _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ' ❑- Well Diameter Sealing Material Itop 50') l <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I 1 INo 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 O <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 /> .ut. p , <br /> Distance to nearest: Well Foundation Property Line s <br /> # i <br /> 'LEACHING LINE ❑ -No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line + <br /> I <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I <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'L6cal 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 mariner 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." t �' •,� ' 4 <br /> The applicant @fI equired ' S. Complete drawing on reverse side. i <br /> t <br /> Signed Title: - _ Date: <br /> f, FO EPARTMENT USE ONLY ; f - <br /> Application Accepted boy -=;4-9 K 5--111 im= 3,f Z Date Area ! I <br /> - <br /> Pit or Grout Inspection b :. M.•• Date Final Inspection by Date`✓-t'_-m <br /> Additional Comments:; � • <br /> I <br /> ❑ Stk 466-6781 - ❑ Lodi 369-362.1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> rApplicant - Return all )copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> � r <br />` T INFp <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'N0. r <br /> _ i , <br /> �F+.EH 13Y41REV.IiH51 A <br /> EH 14-25 c`] <br /> = I <br />