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APPLICATION FOR PERMIT �T <br /> k SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 /I <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 /> A 1� I ( L3-19u e)� <br /> IJ�� Address `` City Lot Size . � l _ PM <br /> t Owner's Name % A 6N.1 - _ Address Phone <br />` I <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 TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br />` FOUNDATIOIN AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other I n Delta Depth of Grout+Seai Type of Grout _ <br /> I I irrigation _.-Approx.Depth I I Eastern Sutface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction <br /> I est uction ❑ Well Diameter Sealing Material {top 50 <br /> Depth S Filler Matecial:f8elow 50'f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION {No septic system permitted if public sewer is <br /> \\rLi available within 200 feet.) O� <br /> Instalfatioh 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 /> 3 LEACHING LINE ❑ No- & Length of lines Total length/size <br /> i, - FILTER BED ❑ Distance to nearest: Well Foundation Property Line j <br /> SEEPAGE PITS I I Depth _Size Number ! <br /> SUMPS LI 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 l <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." 4 <br /> The applicantm call for all required i ctions. Complete drawing on,reverse side. <br /> KSigned X d �� Date: ~� <br /> _ <br /> �DEPA_��IT�,-T.ENT USE O <br /> Application Accepted by o Date-33) l <br /> Area � <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: I <br /> ❑ Stk 466-6781 ❑ Lodi '369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environnt ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 <br /> FEE MOUNT DUE AMOUNT REMITTED CK <br /> CASH <br /> if <br /> INF RECEIVED BY DATE PERMIT NO. <br /> +.EH1324iREV. <br /> EH 1 /gyp/may <br /> 4-26 r f ✓✓✓ f``�J 3✓/moi+/ TO�� <br />