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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. (�,s—& /) <br /> Job Address �,57ie ,� city �f>�/��iitSize Z���X�aM <br /> Owner's Name i' . dam} �l <br /> -1 Phone c� <br /> Contractor's Name�_� V �'l�.nse No.� J Phone„��! �. <br /> — TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DE RUCTION ❑ <br /> PUMP INSTALLATION ❑ e SYSTEM REPAIR OTHER ❑ <br /> r <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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material(top 501 D <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) J <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 �. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG.TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property line � <br /> i <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 Number <br /> SUMPS ❑ 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: "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."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 call all required inspections. Compl awing on reverse side. / �J �jc <br /> Signed /�%?h�Title: ,�—�- � <br /> Date: <br /> FOR DEPARTMENT 11CF nNl Y_ ^___ Q <br /> Applicationi;Accepted by Date\a —\\C) u� Area 011 O <br /> Pit or Grout Inspection by Date Final Inspection by, ��'11—14-1t Date ! HCl-r s <br /> Additional Comments: Q.J. _ a� C <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-71Ur ❑ Tracy 835-6385 <br /> Applicant--Return a* to:-Environmental health Permit/Services 1601 E. Hazelton Ave., P.O.Box 2009,-Stk.,�CA 95201 - <br /> INFEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24(REV.10/81 _ h I _ _ _ _ <br />