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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 34 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 UCity Lot Size PM <br /> i <br /> F a <br /> Owner's Name t/. a -�,� �a-� Address v&' 44J Phone <br /> Contraclor2d�CL _ , . Address ~ 4Lense Nod �� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 <br /> PUMP INSTALLATION Ce\ SYSTEM REPAIR ❑ OTHER D <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 T <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 4 <br /> Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications <br /> {"1 Public 17 Other ❑ Delta Depth of Grout Seal Type of Grout __. O <br /> I Irrigation --Approx. Depth f l I Eastern Surface Seal Installed by <br /> Repair Work Done X Type of Pump.¢ H,P. fiJ[+rl� State Work Done <br /> Well Destruction D Well Diameter Sealing Materialltop 50'1 ' <br /> Depth " Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION')-1 (No-septic system permitted if public sewer is <br /> available within Wfeet:) 31 <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: Waier table depth <br /> "SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: WellFoundation Property Line <br /> Y <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to rsearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS D 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 <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 appficani m fall require i inspections. Complete drawing on reverse side. 1 <br /> � Q <br /> Signed X Title: <br /> � J DEPARTMENT USE ONLY — <br /> Application Accepted by ,�J'd{J( Date Area <br /> Pit or Grout Inspection by Dae Final Inspection by c DateF� <br /> Additional Comments: r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑ Tracy '8j5-6M5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DDE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> FEE -t- �.EH 11-24(REV.1/115) 5 .y G"L + fnr 1'�U6 - <br /> EH 14-26 v J�p <br />