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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTHM1 DISTRICT , <br /> 1601 E. HAZELTON AVE., STOCKTON; CA <br /> ._Telephone (209) 466-6781 <br /> PERMIT EXPIRES i 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 N M9 fpr sewage or No. 1862 for well/pump and the Roles and Regulations of the San Joaquin <br /> Local Health-District. Oro„ <br /> Job Address Y> �S � <br /> r� � dot Size PM <br /> Owner's Name �I Address Phone <br /> Contractor_h15 X & /T#$ /-Address License No­��Phone 46- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1-14 <br /> DISTANCE TO NEAREST: SEPTIC TANK R SEWER LINES <br /> DISPOSAL FLD.-”` PROP. LINE <br /> FOUN13ATION, . AGRICULTURE WELL. OTHER WELL N PITS/SUMPS _ <br /> INTENDED USE --TYPE-OF-WELL WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation LJ� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Dia. of Well Casing Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ,Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done 1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501) L Nr- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public_ sewer is �g <br /> available within 200 feetJ <br /> Installation will serve: Residence_ Commercial r! Other <br /> Number of living units: — Number'of bedroom # <br /> Character of soil to a depth of 3 feet: r�D, � ¢;f + I <br /> SEPTIC TANK Type/Mf "r.' •* Water table depth <br /> g _ Capacity .0 No. Compartments <br /> PKG. TREATMENT PLT. ❑ -'' l ' < Y' Method of QjSposal� <br /> ~ Distance to nearest: Well { Q Foundation / Property Line <br /> +LEACHING LINE P---N-o. & Length of lines Total length/size ' <br /> FILTER BED i❑ Distance to nearest: Well'• 1 Foundation '?DJ Property Line a <br /> SEEPAGE PITS Depth Size 1 <br /> �LI Nylmber <br /> SUMPS ❑ Distance to nearest: Well FoundationProperty Line <br /> LU <br /> DISPOSAL PONDS ❑ - J <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,, Tr <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owneF or licensed agent's signature certifies the following: "I certify that in the performance of.tQ 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." <br /> The appG�anus call fo�allrequi�redlns_2��. ete drawing reverse side. <br /> Signed Title: Date: �- C <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection"6Y —En"4A4AjP-- Date t � <br /> —ft��Final Inspection by Date <br /> Additional Comments:". <br /> SStk 466-6781 ❑ Lodi 369-3&21 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY + <br /> INFO y H DATE PERMIT NO. <br />- + CH 13-24 EH 14-26(REV.t/ab) <br /> l <br />