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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.-"Z,!. , :,_. Lot., , <br /> Size PM <br /> Owner's Name " +'' Address '~ r .'s Phone <br /> ontractor t T i Address ` ' ' ° License No. z ! +J Phone <br /> YPE OF WELLlPUMP: NEW-WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ ,`m ,.SYSTEM REPAIR..C7 s, �,.OTHER 0 <br /> ISTANCE 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 /> V Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia, of Well Casing <br /> 1 Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1 Public Cl Other. , ❑ Delta .Depth of Grout Seal Type of Grout _ <br /> I Irrigation --Approx. Depth l 1 Eastern Surface Seal Installed by _ <br /> epair Work Done ❑ Type of Pump# H.P. State Work Done <br /> ell Destruction ❑ Well Diameter Sealing Material Itop 50') _ <br /> Depth Filler Material (Below 50') <br /> YPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION (No sepiicAU.%Wm permitted if public sewer is <br /> availab ithin 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: a War <br /> EPTiC TANK ❑ Type/Mfg ' Capacity a. Compartm 7 s `. <br /> KG. TREATMENT PLT. p. <br /> '1. ' � ethod of Di sal <br /> Ra <br /> Distance,to F nearest: Well Foundation ope Line �1 <br /> r "'�� V� <br /> RING LINE Cl No. 6 Length of lines Total le th/s e <br /> R BED ❑ Distance to nearest: Well Foundation rope y Lin <br /> re <br /> E PITS 11 Depth 4, <br /> Size Number i <br /> '.., Ll `Distance to neatest. ,Well. Foundation rope Line 1 <br /> POSAL PONDS :. <br /> cart+y that ave repare this application an a or w1 bo or aq�or anccae�wuh a Jo uin county or mantes, state laws, an regulations of the San Joaquin Local Health I I D—) � <br /> ner or licensed agent's signature certifies the following: "I ce if that in the performance of the wdrk,oT which this permit is issued, I shall not <br /> Vny person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> fallowing: "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 /> llws of California." <br /> Da plicant must call for aft required insections. Complete drawing on reverse side. <br /> X Title: ` <br /> f— – 4 Date: <br /> FQ� DEPARTMENT;USE ONLY <br /> pplication Accepted by Data f ' Area <br /> it or Grout Inspection by '}£ `"` Date Final Inspection by_(i 1� 1���y �,�_ Date <br /> Additional Comments: <br /> [I Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 <br /> pplicant - Return all copies to: Environmental Health Permit/Services 1601'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> )+ k <br /> INFO FEE AMOUNT DUE °": AMOUNT REMITTED ' CASH RECEIVED BY DATE PERMIT NO. <br /> ♦.EH t3 4IREV. <br />