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l APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> I 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 the San Joaquin <br /> Local Health District. <br /> Job Address 5/( Ii t City L 1;16 Lot Size PM <br /> Owner's Name <br /> J '�ddro16 Phone <br /> r e Y <br /> Contractor T '�� Address License No. Phone 4` <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PNS� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS`- •`'^­ <br /> D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 71 Public n Other . . l l Delta- y Depth of Grout Seal Type of Grout _ <br /> l 1 I Irrigation —.Approx. Depth t 1 Eastern Surface Seal Installed by 1 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') t <br /> Depth Filler Material /Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (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 4o a depth of-3 feet - Water table depth t <br /> r SEPTIC TANK ❑ Type/Mfg – Capacity No. Compartments <br />' PKG. TREATMENT PLT. ❑ Method of Disposal <br /> l Distance'lto nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Let ngth of lines Total length/size <br /> FILTER BED O Distance to nearest: . Well Foundation Property Line <br /> SEEPAGE PITS I I Depth # Size Number <br /> SUMPS •.. ❑ Distance.to nearest: Well Foundation- Property Line <br /> DISPOSAL PONDS ❑ ! <br /> f 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 /> i rules and regulations of the San Joaquin Local Health District. <br /> i 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 /> f 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 st call r all r uirinspectioins.,6Complete drawing on reverse side. <br /> it Signed X c Title: J /ice Date: r�J <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by DateyQ!5!._ Area <br /> i <br />� Pit or Grout Inspection by 77 Date Ficial Inspection by F T ��/�✓ Date <br /> Additional Comments: Ah <br /> t ❑ Stk 466-678'1 – ❑ Lodi =3621 —0 Manteca 823-7104 ❑ Tracy 835-6385 - <br /> I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA-95201 <br /> FEE t <br /> IfI INFO AMOUNT DUE AMOUNT REMITTED CCASH RECEIVED BY PATE <br /> P/E]RMIT NO. <br /> VJ <br /> k + EK 13-24(REV.1iH5) <br /> EH 14-26 <br />