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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 'S <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1.]0 <br /> (Complete in Triplicate) L ,y <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 AddressCir i <br /> ..., y Lit Size !'M <br /> Owner's Name _ r � i yl. Address �� /r L�/Z� Phone W f�a5 <br /> Contractor AddreSs af,3 67 GGA License N3 PhonV 40¢ <br /> TYPE OF WELL/PUMP: NEW WELL.❑,_ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ r u <br /> DISTANCE TO NEAREST: SEPTIC TANK­- - -SEWER-LINES— - DISPOSAL FL-D—=— PROP. LINE i! <br /> FOUNDATION AGRICULTURE WELL OTHE PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca �T �polf, <br /> Well Excavation Dia. of Well Casing <br /> e <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Casing Specifications <br /> I'1 Public (7l Other elta Depth of Grout Seal Type of Grout _ <br /> Irrigation _-Apprpx' t I I Eastern '-SOrface Seal In'stalled'by-- <br /> _ <br /> Repair Work Done ❑ Ty ump H.P. 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 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—1 Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Charactter 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 /> LEACHING LINE ❑ No: & Length of lines r Total length/size l <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> A - <br /> SEEPAGE PITS i I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Weil Foundation—'Property Line <br /> DISPOSAL PONDS ❑ . <br /> 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. t- - <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 t call for all required ' pections. Complete drawing on reverse side. (� <br /> Signed X a Title:' Date: �' /✓ <br /> q� F DEPA ENT USE ONLY ' <br /> Application Accepted by OT'` -- Date- l Area O <br /> Pit or Grout Inspection Date Final Inspection by Date 'y <br /> Additional Comments: <br /> C] Stk 466-6781 ❑ Lodi 369-3621 ❑ M eco 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Envirorimental 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. A� <br /> INFO <br /> CASH <br /> . EH1 -24PREY.tins! 1`c <br /> ' EH r44-2f1 _ J 1 `Jr�'' tel+ t <br />