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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 the San Joaquin <br /> Local Health District. " <br /> .. � : I ' <br /> Job Address 0 <br /> � - Ci Lot Size PM <br /> Owner's Name Address"rtj �� Phone1 'S3AC <br /> Contracto ""z r Address,-&t767Z_Na Z Z_ Phone��d ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM­REPAIR LJOTHER El <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. <br /> ❑ Industrial t ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack - 0 Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other Q Delta Depth of Grout Seal . Type of Grout <br /> 4 EJ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> ' Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Belo ') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONZcommercial- <br /> ❑ ION DESTRUCTIONF❑Mo septic system permitted if public sewer is <br /> E �,y". available within 200 feet.) <br /> Installation will serve: Residence Other f. y <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: E ��TM- Water table depth 7- <br /> SEPTIC <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well-,Foundation Property Line <br /> LEACHING LINE Total len Na. & Length of lines gt <br /> f � t _ h/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation f Property Line <br /> SEEPAGE PITS ❑ Depth Size Number i <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line J <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: "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."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 applicaohmust call for aIlquired inspections. Complete drawing on reverse side. / <br /> i 7r3fJ �k <br /> Signed Title: Date: <br /> FOR DEPAR ENT USE ONLY <br /> Application Accepted by Date Area <br /> Ph or Grout Inspection b Date Final Inspection by Date <br /> { <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-631 <br /> Applicant- Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE' INFO AMOUNT DUE- AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH13-24MEV.t/s5Y �� 7f'-7f Gr Gt <br /> EH 14-26 b )1v <br /> r <br />