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to _ , :_ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ii <br /> (PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) rh'tolfa�� <br /> heieb made to the San Jo quin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Application Is y , <br /> made in compliance with San Joaquin Cou-nty 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 /> City Lot Size PM <br /> Job Address <br /> .l a S <br /> . Owner's NameAddress Phone <br /> y,g�.��� <br /> Contracto Address 4 - d License n /a Phon <br /> ���-S / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ �_ WELL REPLACEMENT ❑ DESTRUCTION ❑ ! <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL_FLD_ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ELL jPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS <br /> © Industrial ❑ Open Bottom ❑ a Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic IPrivate Cl Gravel Pack- Tracy Type of Casing I Specifications <br /> l'] Public [1 Othe ❑-Delta Depih._of Grout Seal Type of Grout <br /> I 1 Irrigation --Approx.,kDepth i I Eastern ~Surface Seal Installed by <br /> Repair Work Do Type of Pump H.P. * State Work Done <br /> i r <br /> Well De ion ❑ Well Diameter Sealing Material (top 50 <br /> '1' I z <br /> Depth Filler Material (Below WT `` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ! REPAIR/ADDITION I I DESTRUCTIO ENo septic system permitted if public sewer is � <br /> available within 200 feet.I <br /> Installation will serve: Residence Commercial 'Other <br /> Number of living units: Number of bedroomst <br /> Character of soil,to a depth of 3 feet:/ Water,.table depth <br /> SEPTIC TANK 'x � ❑ Type IMfg" Capacity 's r No. Compartments <br /> PKG, TREATMENT P.LT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foondation Property Line <br /> LEACHING LINE ❑ No. & Length of lines { Total length/size [ <br /> FILTER BED ❑ Distance to nearest: !Nell Foundation Property Lirie <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line A <br /> DISPOSAL PONDS C7 it <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Eaws,.,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 /> The applicant ust call for all required inspections. Complete drawing on reverse side. <br /> c A -a- Date <br /> 9 : ry. <br /> Si ned - <br /> Title: <br /> I <br /> ! 'FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Areas <br /> fPit or Grout Inspection by Date Final inspection by Date , <br /> Additional Comments: `3G ` �' <br /> ❑ Stk 46&-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 51k., CA 9 1 <br /> t, FEE 111' <br /> INFO AMOUUNNTrDUE; AMOUNT REMITTED CASH RECEIVED BY DATE "PERMITNO. <br /> EH 13-24 IftEV.I/K 5) <br /> EH 14-26 <br />