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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 and Regulations of San Joaquin <br /> Local Health District. (, )/� <br /> Job Address r �0o k N City&M <br /> Lot Size / !VI <br /> Owner's!Name �e "� �■v� [,lY1A!.__dress � Phone YdY <br /> Contractee LllT W. w)G7� Address017 E License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL-REPLACEMENT ❑ DESTRUCTION ❑ <br /> r <br /> PUMP INSTALLATION ❑ SYSTEM AV1 ❑ 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 PROBLM AREA CONSTRUCTION SPECIFUWN$f <br /> ❑ Industrial ❑ 0 Bottom anteca Dia. of Well ExcavationDia. of Well Casing (" T <br /> ❑ D estic/Private Gravel Pack X El Tracy i' Type of Casing7Statee <br /> *� EType <br /> tions _ w <br /> ublic ❑ Other ❑ Delta """��Depth of-Grout Seal Grout a <br /> ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed � <br /> Repair Work Done ❑ Type of Pump H.P. Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> „yavailable 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 . ,-Capficity, No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ; <br /> 4 j <br /> LEACHING LINE ❑ No.&.Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size `�-. Number <br /> SUMPS ❑ 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 countq ordinances, state laws,-and <br /> rules and regulations of the San Joaquin Local Health District. e ' '- <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." v' <br /> The applicant m ca I for II req Ired i ctians. Complete drawing onside,r arse <br /> s <br /> �. <br /> Signed Title: Date: <br /> r x' <br /> WDate <br /> DEPARTMENT USE ONLY 7Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi.. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83540% <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE I PERMIT NO. <br /> + EH1321(REV. i 8,3) <br /> EH 1428 /� <br /> I <br />