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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 /> PM <br /> Job Address <br /> Owner's Name 11i—._f City q Size <br /> ` 1 04 Q✓ ress _ D `��s Phone <br /> Contractor dress f License No. lbl Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR G 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 C Open Bottom 11 Manteca , Dia.of Well Excavation Dia. f Well Casing <br /> mestic/Private El Gravel Pack C1 Tracy Type of Casing Specifications <br /> M Public Q Other CI Delta Depth of Grout Seal Type of Grout <br /> ! I It(q)a6on ­Approx. Depth ' I Eastern Surface Seal Installed by <br /> Repair Work Done RJ'/Type of Pump H.P. -1 —_ State Work Done <br /> Well Destruction C Well Diameter Sealing Material (top 50') _ <br /> Depth Filter Material (Below 50') -- _------- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 ? REPAIR/ADDITION I I DESTRUCTION i I (Nonseptic systithin m emitted if public sewer is <br /> avaable 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 ❑ Type/Mfg ._._._ Capacity__ ­ No. Compartments ._ <br /> PKG- TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED C Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I l Depth Size .T _ Number <br /> SUMPS L1 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 <br /> rules and regulatio n Joaquin Local Health District. <br /> Home owner or I' nsed agent signature cern the following: "1 certify that in the performance of the work for which this permit is issued, t shall not <br /> employ any p on in such man eras to beco bject rkman's compensation laws of California."Contractor s hiring or subcontracting signature <br /> certifies the (lowing: "I certify tin the a th work ich this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws California." <br /> The appy ant m all requir s to d wing on eve ,de. <br /> Signed Title: `Y.- 'e, Date: �L—fes-� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by !!^�+"`� yJ% Date 7f Lf Area <br /> Pit or Grout Inspection by Data Final Inspection by /t Date <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health PerrrXServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMO NT REMITTED Cx RECEIVED BY DATE PERMIT N0. <br /> INFOgy2 CASH <br /> . EH 1324 eREV.r/H si ` 1 <br /> EH 7426 [[// <br />