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' `.4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,.STOCKTON, CA <br /> 'Telephone (209) 466-6781 ' <br /> PERMIT EXPIRES 1"YEAR FROM DATE ISSUED <br /> r: <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. TMs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$62 for welUpump and the Rules and,Reguiatioadof the San Joaquin <br /> Local Health District. 'r <br /> Job Address '"` ' <br /> City Lot Size_ �X �� �PM" <br /> Owner's Name �+�' Address dC Phone ` ! 9/(./ <br /> Contractor Address License No. Phone <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 /> 4 <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 Excavation Dia- of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other '_ ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ! <br /> 9 _. __Approx, Depth ID Eastern '- Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') 4 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is k <br /> ailable within 200 feet.l <br /> Installation will serve: Residence— Commercial Other Vii"-.A,-y r rff <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:" Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT. ❑ l; s r <br /> Method of Disposal � <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE" ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest:' Well - Foundation Property Line <br /> x i <br /> SEEPAGE PITS ❑ Depth n t° Size Number <br /> SUMPS ❑ 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 applica4t must call for all requA%84,inspections- Complete drawing on reverse side. <br /> Signed X Title: <br /> Rate: � /` � 1 <br /> F DEPARTMENT USEONLY p <br /> �� . U <br /> Application Accepted by Date .tea <br /> Pit or Grout Inspection b e <br /> Pe Y Date Final Inspection by Date <br /> Additional Comments �� (J <br /> ❑ Stk 466-6761 Lodi 369- 1 ❑ Manteca 823 7104 ❑ Tracy 6385 - r' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE �j AMOUNT REMITTED CK If <br /> ASH RECEIVED BY DATE PERMIT'NO. <br /> '+ EH 13-24(REV.wg5) <br /> EH 14-28 <br />