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,F <br /> I�i APPLICATION FOR PERMIT <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> 1631 E. HAZEL T ON AVE., STOCKTON, CA <br /> II Telephone (209) 466-6781 <br /> II PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> . II <br /> I� (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 sr` G; � City Loi Size �� f PM <br /> is J/ II / <br /> Owner's Name �y�'�^ I H _ Address A207 C— ��c- -1iV 5 ,71 Phone <br /> Cbntractor r✓i/Lay 11 _Address a License No. Phone <br /> TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION D <br /> PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS i ; <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 T Ype of Casing Specifications <br /> 11 Public ❑ Other F) Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth! Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO17�(No septic system permitted if public sewer is <br /> II available within 200 feet.) <br /> C, <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: �! Number of bedrooms �p <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: Well Foundation Property Line <br /> li <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED © Distance to nearest: Well Foundation Property Line <br /> A. <br /> r <br /> SEEPAGE PITS E3Depth Size Number <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ II <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." 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> is <br /> The applican must call for all reuired i spections. Complete drawing on reverse side. <br /> i Signed Title: Date: <br /> II FOR DEPA TIVIENT USE ONLY G <br /> Application Accepted byZDate ��f_/�1 Area <br /> (� rp—r / i r c�i 1t d' Date <br /> Pit or Grout Inspection by Da <br /> Final l Inspection by f <br /> Additional Comments: <br /> I ❑ Stk 466-Ml Lodi 11369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> I Applicant- Return all opi to:`Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> t + EH 13-241REV.1/as) it v <br /> EK 1426 <br /> II <br />