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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I <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 Sart Joaquin <br /> Local Health District. <br /> it /� �/ f <br /> Job Address �/ (%11�~ e City 't Lot Size 7�7` I sb PM <br /> ,/k.4 1 N I <br /> Owner's Name Address 1;2 Gd /74, '`► Phone Tq a 13 1 j <br /> Contractor UF Address 0 � _ License No. 7 �} 9/ Phone <br /> i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ tWELL REPLACEMENT ❑ DESTRUCTION ❑ 2 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ JI <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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11!Y <br /> r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth.of,Grout S al Zk Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern ISurface Seal Installed by <br /> J 1%Repair Work Done E], Type of Pump H.P. t 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 ❑ REPAIR/ADDITION ❑ DESTRUCTION^INo septic system permitted if public sewer is <br /> I _ _ ?vailable within 200 feet!) t <br /> Installation will serve: Residence_ Commercial_ Other ,l <br /> Number of living units: Number of bedrooms b4 <br /> Character of soil to a depth of 3 feet: Water table depth , <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ � _ ,.,,.,r,,,Method of Disposal �f <br /> Distance to nearest: Well Foundation Property Line <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 <br /> Number ' <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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: "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."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 m all for all requi inspections. Complete drawing on��re?verse side. <br /> Signed Title: CQ. Date: <br /> FOR DEPARTMENT USE ONLY �j <br /> Application Accepted by Date ` 4�Area <br /> Pit or Grout Inspection by Date Final inspection by Daley <br /> Additional Comments: oat <br /> - <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 13241REV.r/55) p„a <br /> EH 14-26 <br />