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APPLICATION FOR PERMIT l�C J <br /> E A SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,,STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> { PERMIT EXPIRES 1.YEAR FROM DAT_ E ISSUED ..: T, <br /> ,�'1':, . <br /> (Complete in Triplicate) 5-r? <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work <br /> herein' made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regu ationsof the San'Joaqu is <br /> n <br /> ! Local Health District. <br /> �f w <br /> Job Address � �]' <�.�,� V � Ci �/ <br /> City � Lot Size PM <br /> Owner's Name Address ! �J <br /> �G r /s J C JCS"�� <br /> Phone <br /> f <br /> Contractor. ,Address <br /> TYPE OF WELL/PUMP: License No. Phone <br /> NEW WELL ❑ <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ L <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy <br /> Dia. of Well Casing <br /> Type of Casing <br /> -1 Public ❑ Other ❑ Delta Specifications <br /> Depth of Grout Seal <br /> Ll -��Type of GP -�- <br /> Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by # 9 <br /> Repair Work Done El Type of Pump H p � <br /> Well Destruction ❑ Well Diameter by <br /> Work Doney <br /> Sealing Material (top 50')" <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONS- (No septic system permitted if public sewer is <br /> Installation will serve: Residence= Commercial available within 200 feet,) I <br /> Other + z <br /> Number of living units: Number of bedrooms I <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth r <br /> ❑ Type/Mfg Capacity .No. Compartments 3 I <br /> PKG. TREATMENT PLT. ❑ - <br /> Method of Disposal <br /> Distance t 'nearest: Well Foundation Property Line S <br /> LEACHING LINEI <br /> ❑ No. & Length of lines Tata) length/size <br /> FILTER SED 7-1Distanceto nearest: Well <br /> Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS Number <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS Property Line <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 <br /> certifies the followin pehis pen laws of California."lContractor's hiring or sub-contracting signature <br /> g:"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 app'cant must ail(or all re fired inspegtions. Complete drawing on reverse`side.' "'= - <br /> Signed Title: , <br /> Date: <br /> FOR DEPARTMENT USE ONLY y <br /> Application Accepted'by <br /> Date Area <br /> Pit or Grout inspection by I <br /> Date Final Inspection by Date <br /> Additional Comments: [r)4-..I <br /> ❑ Stk 46&6781 ❑ Lath 369 3621 J ❑ Manteca 823-7104 LJ ]racy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTEDMH <br /> INFO RECEIVED BY DATE,f� PERMIT�'NO.+ EH14-29{REV.t/a51 �Vd V� <br /> EN 14-ZB !I <br />