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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) 1 <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 waif/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District_.. <br /> Job Address' City�` .c— Loi Size ' PM <br /> {� Q � .sem <br /> Owner's Name Address Phone <br /> -IF <br /> Contractor's Name <br /> r License No. [ -34 75 9 Phoney6 - 6 <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 FLD. PROP.,LINE. <br /> FOUNDATION AGRICULTURE WELL _._.__— OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> O Domestic/Private \❑ Gravel Pack I-', Tracy Type of Casing— Specifications <br /> 0 Public C Other Ll Delta Depth of Grout Seal _ Type of Grout 1 <br /> G Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done .•C^—Type of Pump-- - H.P. State Work Done (� <br /> Well Destruction L Well Diameter Sealing Material ttop 501 `Q <br /> t Depth Filler Material (Below 50'1 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public-sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence commercial Other <br /> Number of living units: / Number of bedrooms. <br /> Character of soil to a depth of 3 feet: ---Water table depth ` <br /> SEPTIC TANK C TypefMfg Capacity No, Compartments <br /> PKG. TREATMENT,PLT.O # Method of Disposal <br /> t Distance to nearest: Well Foundation Property Line - -1 <br /> LEACHING LINE ;?c No. & Length of lines Total length/size r <br /> FILTER BED C Distance to nearest: Weil Foundation /6`4" Property Line <br /> SEEPAGE PITS O Depth Size_ Number <br /> 1 <br /> Foundation -� -Property Line'"- <br /> SUMPS _ Distance to nearest: Well _ _ <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 f ounty ordinances,state laws, and <br /> rules and regulations of the San Joaquin Local Health District. is issued,.l shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit <br /> employ any person in such manner as to become subject to workman's compensation laws of California_" Contractor s.tiiring or sub contracting signature f <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- i <br /> tion laws of California." <br /> The applicant r li mqu' nspe s. Complete drawing on reverse side. F f <br /> Date: <br /> Signed X <br /> F-Title: <br /> FOR:DEPARTMENT USE ONLY I ` <br /> /2 <br /> /< Date Asea <br /> Application Accepted by ' , <br /> Pit or Grout Inspection by Date Final Inspection by ' l Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 C Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009, Stk., CA 95201 ` <br /> FEE AMOUNT DUE AMOUNT REMITTED CCAKSH RECEIVED BY F DATE PERMITNO. ,' <br /> INFO ` <br /> r E+1 1320(REV.101831 ' :� i l _ -` {�19/Cit� —LS f..t ci <br /> EH 14-26 �'• - - O_1 <br />