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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Z* 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> f 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 /> rJ.��Y1 City +�L Lot Size PM <br /> Job Address a <br /> �,y�� Address SU`l^~p-~' Phonei���t+� kk <br /> Owner's Name j <br /> 1 G-s"7 9'l'3 I <br /> Contractor f`it 1� Address 11RE)of l40 Sf l IIL-teense No.2 g <br /> TYPE OF WELL/PUMP: NEW WELL &t `1NELL REPLACEMENT © DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM R PAIR ❑ 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 fl <br /> ❑ Irt:dvstt"fa1�'1(sy���i1i ❑ Open Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ <br /> Domestic/Private NGravel Pack/S" ❑ Tracy Type of Casing SC 1n 40 P11cr, Specifications <br /> FI Public t-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> -- <br /> k 1 Irrigation < (0 C J..Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 50') —� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l-I DESTRUCTION I I (No septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <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 <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Deptfl <br /> Size Number <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> I 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, an <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, l shall no <br /> F 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 m t all for all r uiTo ins ons. Complete drawing on reverse side. <br /> Signed X <br /> Title: Fco-s ,, fie I 1� Data: <br /> F <br /> FO PA USE ONLY c <br /> D I:>5� <br /> I <br /> Application Accepted by date A-Lea <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 L7 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT <br /> INFO <br /> ♦.EH 13-24(REV. /H 5) <br /> EH t4-26 <br />