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APPLICATION FOR PERMIT <br /> 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 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 AddressiX%13�� 1ilJ /L _ City Lot Size a'CA'e-15 PM <br /> OFr <br /> Owner's Name Address hone <br /> Contracto f Pili f Address 40 ,� <br /> License No��gy.?a6 Phone G <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 /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial i r❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 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 <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 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 7A== <br /> Character of soil to a depth of 3 feet: Water table depth ® , <br /> SEPTIC TANK ❑ Type/Mfg Capacity Nb."-Compartments <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: Well._ Foundation Property Line <br /> v` r 1- <br /> LEACHING LINE UK'No. & Length of lines LL +Total length/size <br /> ` X K <br /> FILTER BED ❑ Distance to nearest: -Well Sd _ Foundation 0 Property Line .. <br /> -SEEPAGE PITS Depth — w ~Size _ .. Number ' <br /> SUMPS ❑ Distance to nearest: -Well /f�D` Foundation _ Property Line &S7 <br /> DISPOSAL PONDS <br /> l hereby certify that I have prepared this applicatioh and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <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, 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 applicant m%tcall for squired inspections. Complete drawing on reverse side. p <br /> Signed X Title: Date: }` d / <br /> 0 FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: e <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 1IN(REV.t/"') /�/] <br /> EH 14-M V E5- � _ <br />