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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZE 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 heieby 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 /> g L tQ City g l0 G rl0 Lot Size PM <br /> Job Address <br /> Owner's Name . ^+ r A.4 AA 7'Lt V Address <br /> Contractor <br /> F Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial <br /> ❑ OPen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f7 Public n Other P Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ..Approx. Depth L I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material [top <br /> Depth Filler Material (B0' — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRlADDITIO l I DESTRUCTION' IN eptic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence X Commercial— Other . <br /> Number of living units: 12— Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK a Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 1 Distance to nearest: Well Foundation Property Line <br /># LEACHING LINE ❑ No. & Length of lines Total length/size <br /> l FILTER SED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> II 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 <br /> rules and regulations of the San Joaquin Local Health Di?trict.— <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 applican ust call for all required inspec ons. Complete drawing on reverse side. <br /> 6—/?? <br /> Signed X <br /> Title: Date: <br /> *. ;{ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area Date <br /> Date e <br /> f <br /> Pit or Grout Inspection by - Date Final Inspection by � <br /> Additional Comments: <br /> i❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> `Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Sox 2009, Silk., GA 95201 <br /> y <br /> FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> � INFO <br /> +.EH 13-24 IREV.i 1 x 51 <br /> EH 14-26 <br />