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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. <br /> Job Address _ , , 1 <br /> ` City����t Size PM <br /> Owner's Name /C _� 1 y <br /> ;Address �l�3 ` ��© 1 <br /> /y Phone <br /> Contractor Address - .�" <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i <br /> DISPOSAL FLD. — PROP. LINE n <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �.. <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ❑ Public F1 Other Specifications <br /> }C7 Delta Depth of Groui 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 ❑ Well Diameter Sealing Material (top 501 / <br /> Depthy+ <br /> Filter Material (Below 50') f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑- DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> _ <br /> Installation will serve: Residence Commercial— Other i <br /> Number of living units: Number of bedrooms ®� x <br /> Character of soil to a depth of 3 feet: Water table depth f <br /> SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> -Distance to nearest: Well Foundation Property Line j <br /> LEACHING LINE ❑--No. & Length of lines LL Total length/size <br /> FILTER BED ❑ Distance to nearest:" Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number ..� <br /> SUMPS D 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 f <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 4 <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 appliiccaant,#rust call for all require sections. Complete drawing on r verse side. <br /> Signed �i9°L� .d ` <br /> — Title:- �f' ! '"'� <br /> Dater / <br /> FOR DEPARTMENT USE ONLY �tiw.. <br /> Application Accepted by <br /> Date Area <br /> Pit or rout pection �- <br /> M5 <br /> Date Final Insp cti n by - _ ;, - DateAdditfona! Commen❑ Stk 4&6-6781 ❑ Lodi 369 3621 ❑ Manteca -7104 ❑ Tracy 835-6 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO ";7-3! <br /> ASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24{qEV,iin51 ✓ i G�fJ 0s <br /> EH 14-ZB � <br /> i <br />