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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT + <br /> 1601 E. HAZEL 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 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 /> Job Address City -5 SAN• Lot Size PM <br /> Owner's Name XIAI Address Phone <br /> p �ND' � 5ys, I �r� Phone 9�/-.�� <br /> Contractor 1"IM&M / Address a License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ;F, REPAJ74E;WAQTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL I OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I <br /> ❑ Public El Other El Delta Depth of Grout Seal Type of Grout <br /> 1 i <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump -5-&4R H.P. j — State Work Done Au Q,1ff t FC'V%E- <br /> Well Destruction ElWell Diameter Sealing Material {top 501 �ffLla_Sip &EE1 <br /> Depth Filler Material {Below 501 N500 �� Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted if public sewer is l <br /> r available within 200 feet.) T" <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 'Y I Water table depth <br /> SEPTIC TANK ❑ Type.IMf 9��-- ;�l °t Capacity No. Compartments ' <br /> _., <br /> PKG. TREATMENT PLT. ❑ zsz rl-' Method of Disposal <br /> Y <br /> Distance to nearest: Well 1 Foundation Property Line <br /> JI-LEACHING LINE ❑ :No. '111' <br /> LEACHING lines r Total length/size 1 <br /> i <br /> FILTER BED 1-1Distance"Id nearest: Well I Foundation Property Linn <br /> SEEPAGE PITS 0- Depth! ^" Size Number <br /> I� SUMPS ❑ Distance to nearest. Well = Foundation s Property Line <br /> I <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 /> r <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, 1 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." r, <br /> The applicant m pr 11 requir ctions. Complete drawing on reverse e. <br /> �+ <br /> Signed Title: Date: v <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area dZ <br /> Pit or Grout Inspection by Date Final Inpection by - Date <br /> k � - <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy, 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. <br /> INFO <br /> i <br /> + EH 13-24 rREV.t/851 <br /> I EH 14-28 <br />