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APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA t <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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. r r <br /> Job Address CityS TKA Iy` Lot Size PM <br /> Owner's Name �X Address / �' ^� �N Phone 70 <br /> Contractor_ { ddress 7 N•WPI !�L t� License No. a Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 i ❑ 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 _.—Approx. Depth ❑ 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 S <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: ResidenceCommercial— 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 ' r No. Compartments <br /> PKG. TREATMENT PLT. C1Method of Disposal <br /> Distance to nearest: Well Foundation ~� Property Line <br /> LEACHING LINE ❑ No. & Length of Iinesul Total length/size <br /> FILTER BED ❑ Distance to nearest: } Well Foundation f Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: ° ",,-Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> i <br /> i. <br /> The aQplicant us call for al fired i s ctians. mplete drawing on-reverse side: <br /> -�--� , <br /> Signed X Title: � A��'n -�:� Date: <br /> FOR DEPARTMENT USE ONLY <70 <br /> Application Accepted by Date r Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> U <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 LJ 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 /> k <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO � G <br /> + EH 13-241REV.1/85) f �-✓f r <br /> EH 14-28 <br />