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APPLICATION FOR PERMIT <br /> .�' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 andlor 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 City*.q� Lot Size D� PM <br /> Owner's Name Address �'/���-�_ __ _ Phone X (47-7- <br /> Contractor r Address _�C!q!'7� - '- License No Y7 Phone 4w <br /> TYPE OF WELLiPUMP: NEW WELL D WELL REPLACEMENT r DESTRUCTION Ll <br /> PUMP INSTALLATION O SYSTEM REPAIR F. OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 1 FOUNDATION .. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA71ONS <br /> LJ Industrial i r1 Open Bottom f; Manteca Dia. of Well Excavation Dia. of Well Casing _ <br /> 17 Domestic/Private. D Gravel Pack C Tracy Type of Casing Specifications- <br /> "I Public F. Other F t Delta Depth of Grout Seal Type of Grout _ tt <br /> I I Irrigation ---_Approx. Depth I I Eastern Surface Seal Installed by L _ <br /> Repair Work Done I 11 Type of Pump H.P. State Work Done_ <br /> Well Destruction C Well Diameter Sealing Material ltop 50') f .� <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I ' INo septic system pormrtted if public sewer is <br /> t avaddble within 21X1}eel.) <br /> 1 i <br /> Installation will serve: Residence 1.. Commercial_-____ ther.._....___.-_._. <br /> Number of living units: A— Number4((( Brooms - <br /> Character of soil to a depth of 3 feet: Les d ilI Water table depth <br /> SEPTIC TANK I n Type/Mfg Capacity,___ _____ No. Compartments <br /> PKG- TREATMENT PLT. i7 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ~rte <br /> �LFACHiING,LINE ' Ll No. & Length of lines Total length/size <br /> FILTER BEDr Fl Distance m nearest: Well Foundation Property Line <br /> SEEPAGE PITS AJ/(lepthV ,2 S t Size yr Number _ <br /> + <br /> SU1 sy' Q{ Property <br /> MPS LI Distance to nearest: Well Foundation \ } <br /> DISPOSAL PONDS l <br /> I hereby certify that I have prepared this application and that the work will be done in,`accordance with San Joaquin�couniy;ordinances, stattl laws, an <br /> rules and regulations of the San Joaquin Local Health DFstrict.n ` I <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 n <br /> employ any porsoniin such manner as to become subject'to w&&an's compensation laws of-California."Contractor's hiring ori sub-contracting signal <br /> certifies the totlowing: "I certify that in the performance of the vtork fpf vvhic4[his permit is issued, I shall employ persons subject to workman's i ompensa- <br /> tion laws of California." �` 1 <br /> I <br /> The applicam c�I or all requi in coons. Complete dfawing�oonn reverse side. t I <br /> Signed X I Title: (! k/00CA r ! Date: <br /> fr ` I <br /> FOA DrEPARTfiAENT ITS(E ONLY <br /> Application Accepted by i^` V�Date Area <br /> CPi or Grout Inspection by at - _ Final Inspection by at <br /> Additional Comments: j 7 r <br /> F7 Stk 466-6781 _r1 Lodi:369--k21)1 v r'd MIanteca t`i323,7104 O-Tracy[ 835-6385 f <br /> Applicant - Return all copies to: Environ menta l•Health..Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 S G//P CI� <br /> r <br /> FEE <br /> NFO AMOUNT DUE AMOUNT REMITII•ED- CK H; RECEIVED BY 1� DATE PERMI7 N0. <br /> ♦ EM EH 32e 1REV.1­4 5; <br /> O 0 <br />