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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 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 an4 Regulations of the San Joaquin <br /> Local Health District. F <br /> Job Address � _� .._ <br /> A J 81 <br /> 6 <br /> 1. <br /> -e� City . Lot Size PM <br /> Owner's Name Address 1209--w, lc] l-11I` Phone 3 3!q`_�JS2 I <br /> Contractor's Name License No. 2 32— <br /> TYPE OF WELL/PUMP: NEW WELL ❑ — Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION Ll 1-1 <br /> REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD.— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> UJ Domestic/Private ❑ Gravel Pack Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Tracy Type of Casing--_ <br /> El Public Ll Other Specifications <br /> ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation _—Approx. Depth ❑ Eastern Type of Grout <br /> ,Repair Work Done Ll Type of Pum Surface Seal Installed by <br /> Pump H.P. State Work Done <br /> Wel! Destruction ❑ Well Diameter <br /> Sealing Materia! atop 501) <br /> Depth Filler Material (Below 501) _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LlREPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial, Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments �— <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: WellTotal length/size <br /> Foundation Property Line <br /> SEEPAGE PITS ❑ Depth <br /> SUMPS ❑ DiSize — Number <br /> Distance to nearest: Well r <br /> DISPOSAL PONDS Cl Property Property Line <br /> 1 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 tion laws of California." p y persons subject to workman's compensa- <br /> The applicant must all for all re inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: h ��' 1_ <br /> --- CtJ <br /> FOR EPARTMENT USE ONLY Date:, <br /> Application Accepted by <br /> Date 4' to Area 1 <br /> Pit or Grout Inspection by <br /> Date-- Fina! Inspection by <br /> Additional Comments: <br /> Date <br /> ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104Tracy <br /> 6,3 85 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Haze!on Ave, P.OP.O . Box 2009, Stk., CA 95201 <br /> FEE AMUE OUNT D _ <br /> INFO AMOUNT REMITTED K � RECEIVED BY <br /> DATE PERMIT NO. <br /> + EH 13-21(REV, 10183) <br /> EH 1426 <br />