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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6761 <br /> r <br /> PERMIT EXPIRES 7'YEAR FROM DATE ISSUED <br /> r (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 wo -4. e- City L-tnden _ Lot Size PM <br /> F ' <br /> +. Owner's Name �� ��+'• QI` Address 4 r�dC��' �' V ws�d� Phone �y <br /> Contr <br /> h Address License No. a *X Phone aG <br /> TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION 171 <br /> PUMP INSTALLATION .1K SYSTEM REPAIR D OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I F. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic!Private ❑ Gravel.Pack ❑ Tracy Type of�Ca's•�g S� Specifications /(d DU 1C <br /> + F1 Public Ll Other n Delta Depth of Grout Seal Type of t Grout <br /> rA.Irrigation S30 ..Approx. Depth l l Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pumpt�._ H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> V <br /> Depth Filler Material (Below 501 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:i REPAIR/ADDITION l I DESTRUCTION f I (No septic system permitted if public sewer is <br /> available within 200 feet.) c� <br /> Installation will serve: Residence_ Commercial— Other �\ <br /> F' Number of living units: Number of bedrooms <br /> f Character of soil to a depth of 3 f t: Water table depth <br /> I SEPTIC TANK ❑ Type/Mf Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance ton rest: Well Foundation Property fine <br /> F.3 LEACHING LINE •❑ No. & Length of It es Total length/size' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> ri SEEPAGE PITS l I 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 /> F 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 /> F The pplicant m s call fo all r uir inspections. CoQnplete drawing on verse side <br /> Signed Title: Date: <br /> F FOR DEPARTMENT USE ONLY <br /> r Application Accepted by Date S Area <br /> I <br /> F <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> i <br /> r <br /> 11Stk 466-6781 F) Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> t FEE AMOUNT DUE AMOUNT R ITTED CA H RECEIVED BY DATE PERMITNO. <br /> INFO <br /> 1IIREV.1 5r <br /> �� IAI 17 <br />