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F <br /> APPLICATION FOR PERMIT <br /> f4 fl SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I 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 /> 4 Local Health District. <br /> Job Address Q City Lot Size PM <br /> Owner's Name -D, Address (�. ��� <br /> Phone <br /> Contractor Address ^"� r" License Phan —' /'f � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION .SYSTEM REPAIR ❑ OTHER ❑ i <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 ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationI <br /> Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public <br /> F1 Other n Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation ­Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump „ H.P. 1 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50') <br /> Depth Filler Material (Below 501 n <br /> TYPE OF SEPTIC WORK: "NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> •^ �— - "-.,, ---�.- _ available within 200 feet.) <br /> Installation will serve: ResidencCommercial_ Other <br /> Number of living units: Number of bedrooms <br /> O r <br /> Character of soil to a-depth of 3 feet! Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity- No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ) <br /> Distance to nearest: --.,We11 r Foci ation Property Line <br /> LEACHING LINE Cl No. & Length of lines <br /> Total length/size <br /> FiLTER BED ❑ Distance to nearest: Well Property Line <br /> p _ Foundation-#" ' <br /> SEEPAGE PITS I 1 Depth Size -�,Number <br /> SUMPS L7 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 Sari Joaquin Local Health 03trict. j <br /> Home owner or licensed agent's signature certifies the following: ',')-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 mu f all require i pections. Complete drawing on reverse side. <br /> Signed X ,� Title: Date: -A—X49--3 O _ <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3 �� Area -216 <br /> Pit or Grout Inspection by Date Final Inspection by Date 3 /3 0 <br /> Additional Comments: <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 /> . I <br /> FEE AMOUNT DUE AMOUNT REMITTED'' GK - RECEIVED BY <br /> • INFO .CASH`' DATE EPERMIT'INI]0. <br /> d EH 13-24(REV.I 51 <br /> EH 14-28 EF <br /> t <br /> t <br />