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APPLICATION FOR PERMIT <br /> III{ SAN JOAQUIN LOCAL HEALTH DISTRICT <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 he+eby 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. oo <br /> /f{.� „ <br /> 2 <br /> Job Address � -J UCCity Lot Size PM <br /> Owner's Na � Address , Phone <br /> Contractor ! 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 TAN+K 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 /> 7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well'Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r <br /> F] Public 1-1 Other ( 1`7 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by n , <br /> r - W <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter SealingMaterial (top50'1 <br /> V <br /> Depth Filler Material 18elow 50'1 lJV <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i-1 REPAIR/ADDITION i 1 DESTRUCTIO I (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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Dispose! <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth i Size Number <br /> SUMPS ❑ Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS ❑ JI <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 Inot <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, Iemploy any person in such manner <br /> as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting 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 ction laws of California." i <br /> The applicant 1must call for re r spections. Complete drawing on reverse side. <br /> Signed X / , .�. - X `� <br /> Title: _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date -A <br /> 1— '-" Area <br /> Pit or Grout Inspection by Date Fina! Inspection In� /�! Date <br /> 1 1-11 Additional Comments: 41 1,17 <br /> ❑ Stk 466-6781 odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all, spies to: Environmentaf Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 1009, Stk., CA 95201FEE <br /> \R <br /> 1 1 <br /> INFO AMOUNT DIE ' AMOUNT REMITTED K CASH RECEIVED BY DATE G, PERMIT'NO. <br /> ..EH 14-2t1 IHEV.1/fir,; �� / r�`� / !J& .l <br />