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t APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 4 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. IB&2 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ._.. 4 City_��� Lot Size PM <br /> Owner's Name w _¢'Uy Address}= + Phone 1 <br /> i <br /> Contractor's Name aaolmuense No. L'� Phone <br /> TYPE OF WELL/PUMP: NEW WELLED WELL REPLACEMENT ❑ DESTRUCTION C <br /> PUMP INSTALLATION ❑R SYSTEM REPAIR D OTHER D <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL _— PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack _ .� D.Trecy—..._ Type of Casing Specifications <br /> ❑ Public �'�.❑ Other 1 1-1DeltaI Ddrpth of Grout Seal Type of Grout-. <br /> — by— <br /> Repair <br /> ❑ IrrigationApprox..Depth CJ 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 50') <br /> Depth i f•_ – 'Filler Material iBelow 50') <br /> TYPE-OF-SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 7,tDESTRUCTION G (No septic system permitted if public sewer is �– <br /> Installation will serve: Residence Commercial Other <br /> t kT available within 200 feet.) <br /> Number of living units: 4— Number of bedrooms' <br /> Character of soil to a depth of 3 feet: . _ /� Water table depth <br /> SEPTIC TANK n Type/Mfg 140!22 Capacity_ No. Compartments <br /> l PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well I PO Foundation Property Line <br /> r 7 <br /> LEACHING LINE D No. & Length of tines f Total length/size V ) <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t-- <br /> SEEPAGE PITS Depth Size 3 3 Number <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C <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 must c t foal requ' 'nspections. Cplate rawing on reverse side. <br /> Signed �j't Title: Date: h1q <br /> ,� <br /> {(� FOR DEPARTMENT U5£ONLY �f <br /> Application Accepted by api.,. !t& s<waaNzkditgr� Date_ Area b { <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> .LJ Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0OD . <br /> +EH 13.241REY.701931 <br /> EM 1448 <br />