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�X r <br /> APPLICATION FOR PERMIT 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,.STOCKTON, CA No we <br /> Telephone (209) 466-67$1 \,.t� <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.aboication 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 /> ~l C City Lot Siz PM <br /> Job AddressAL3 <br /> Owner's NameXQ9r Address :2 Phoned <br /> �� Address _ License N Phon <br /> Contracto <br /> TYPE OF WELL/PUMP: NEW WELL LJWELL REPLACEMENT LJDESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> p Industrial p <br /> ❑ Domestic/Private El Gravel Pack ❑ Type of Casing 9 Specifications <br /> LlPublic ❑ Other 17Delta Depth of Grout Sea! Type of Grout <br /> ❑ Irrigation `' --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done.i ❑ Type of Pump H-P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material ltop 501 <br /> -` Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION [IDESTRUCTION (Nail bptticvsh system permitted if public sewer is <br /> in 200 feet.) <br /> i - <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: Water table depth <br /> ` SEPTIC TANK FType/Mfg ``Capacity - No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑- No. & Length of lines Total length/size <br /> k FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> SUMPS ❑ Distance to nearest:- Welk Foundation Property Line <br /> DISPOSAL PONDS ❑ `y ;�" <br /> !.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."Contractors 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 ust call for all required inspections. Complete drawing on reverse side., <br /> VLA Title. ---'-ii Date: <br /> Signed r - - <br /> I FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date � Area L/ <br /> r ✓d <br /> Pit or Grout Inspection <br /> Date Final Inspection by Date <br /> Additional Comments: w /V <br /> ❑ Stk 466 6781 ❑ Lodi 369 1 ❑ Manteca 823-7104 ❑ Tracy 835- <br /> 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT N0. <br /> y AMOUNT DUE AMOUNT REMITTED CASH <br /> j INFO <br /> E + EH13-24IREy.t/e51 zg <br /> EH 14-20 <br />