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r APPLICATION FOR PERMIT W' jI ( <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E..HAZELTON`4)E„ STOCKTON, CA15 ,• <br />7Telephone <br />120911'466-6781 ti l <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Complete in Triplicate)Vxy O. i i i CAL1110ES <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein 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 Districts <br />Job Address Cit of Size PM j <br />70-3q <br />Owner's Name r$ 4 Address ed Phone <br />If a <br />Contractor Address l E License No. A 7 Phone C <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 />I <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 <br />Industrial 0 Open Bottom Manteca Dia.-of Well Excavation Dia. of Well Casing <br />El Domestic/Private El Gravel Pack Tracy Type of Casing Specifications r <br />I'1 Public Cl Other Delta Depth of Grout Seal Type of Grout <br />I I Irrigation Approx.pDept 1 I E stern Sriace Seal Installed by F <br />Repair Work Done Ll- Type of Pum H.P.f/ State Work Done <br />E <br />Well Destruction Well Diameter Sealing Material (top 50'1 <br />R <br />Depth filler Material (Below 501 <br />TYPE, OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION 111 DESTRUCTION I l (No septic system permitted if public sewer is <br />1 available within 200 feet.) <br />Installation will serve: Residence _ - Commercial— Other j <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth V . <br />SEPTIC TANK Type/Mfg Capacity No. Compartments l <br />PKG. TREATMENT PLT. <br />I Method of Disposal <br />Distance to nearest: Well FourFdation Property.Line <br />LEACHING LINE No.-& Length of lines I Total length/size <br />FILTER BED Distance to nearest: Wellb Foundation Property Line <br />p <br />SEEPAGE PITS II Depth Size P <br />Number <br />j __ rSUMPSDistancetonearest: Well Foundation .s Property Line <br />DISPOSAL PONDS <br />I hereby certify that I have prepared this application and that the work will be dontonaccordance with'San Joaquin county ordinances, state laws, and <br />rules and reguI do f the San Joaquin Local Health District. <br />Home owner icensed nt's signature certifies the following: "I certify th tin the pert mbnce of the work for which this permit is issued, I shall not <br />employ apars in such ctannerastobecosubjeorkman's compensation laws of California.;' Contractor's hiring or sub-contracting signature <br />certifie he follo ng: "!ce fy at'in th pe r ce f t e w 'which thi rmit is issued,I shall employ persons subject to workman's compensa- <br />tion t sof Califo nia.':. ,& <br />r t- <br />The pplicdnt mus cat) al regwre •gins plate- rawing-on,r <br />Sign X Title: Wry Date: <br />4 <br />Fa-R'DEPARTMENT USE ONLY <br />Application Accepted by 9 TAS Date Area <br />Pit or Grout Inspection by Date Final Inspection by Date_/1.2- Sr <br />Additional Comments: <br />Stk 466=8781 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 />CK <br />INFO <br />FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br />EH 1321 fREV. <br />EH 11-28