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y APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T 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 /> i E <br /> Job Address <br /> S2— L q Lot Size I PM I's <br /> ._ - Y) City- <br /> I <br /> P <br /> Owner's !Name a<Y Address ff Phone <br /> • � _ 07a�- hone <br /> Contracto4._ h ���-h Address License No. ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑J WELL REPLACEMENT ❑ DESTRUCTION LJPUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i'1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout —. <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by - [ <br /> Repair Work Done LlType of Pumpj 4. H.P. State Work Done_ ) <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth - Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> 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 1_ <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Q> <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Weil Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total lengthtsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS Ll 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 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: "l 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 ." Contractors 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 st call <br /> for all <br /> required inspections. Complete drawing reverse side. <br /> Signed . Title: oc c.� ' Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by IIICHCA4.o Date )Q A7 Area_ r\ <br /> Pit or Grout Inspection by Date Final Inspection by Date/ Fes= <br /> Additional Comments: <br /> ❑Stk 466-6781 ❑ 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, Stk., CA 95201 <br /> i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO /[ CASH �j <br /> a.EH 1124IREV.1/851 JS <br /> EH 14-28 O tie �)ts ��/ <br /> r <br />