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1 <br /> i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �. 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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 y <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. �j <br /> t <br /> JobAddress ✓—71 s <br /> ' City Lot Size `= M <br /> f � G� <br /> Owner's Name 4n Address l U`T� �/ � J d���hone 5�3 O <br /> Contractor's Name License No.�' _ <br /> T- Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR-0 . . .OTHER ❑ <br />+ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> fl DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS �1 <br /> Ll Industrial ET Open Bottom ❑ Manteca Dia. of Well Excavation ` <br /> 11Domestic/Private ElGravel Pack El 'Tracy T Dia. of Well Casing <br /> ype of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation ;Approx. Depth EJ Eastern Surface Seal Installed by Type of Grout <br /> Repair Work Done ❑ Type of Pump H.P. ` <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> —Iasia Brien will serve: Residence Commercial, Other available within 200 feet.) <br /> Number of living.units:. Number of b 1 <br /> Character of soil to a depth of 3 feet: I <br /> SEPTIC TANK Water table depth ��ll r ` <br /> f ❑ Type/Mfg Capacity `'"� No. Compartments <br /> PKG. TREATMENT PLT. ❑ e <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Prope7 Line <br /> LEACHING LINEImo' ml <br /> !!!10 1,❑ No. & Length of lines <br /> FILTER BED Total length/size <br /> ❑ Distance to nearest: -Well Foundation r Pro <br /> perry Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS Number <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must r all ctions. Complete drawing on re side. <br /> Signed _ <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY " <br /> Application Accepted by <br /> ._ Date ` [ Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date <br /> Additional Comments: U s <br /> ❑ Stk 466 6781 ❑ Lodi 369 362 ❑ Manteca <br /> 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return ali,coples to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> c <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> - INFO CASH RECEIVED BY DATE PERMIT''NO. <br /> + EH 13-24(REY,10/83) <br /> EH 1426 <br />