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Ik <br /> APPLICATION FOR PERMIT �! <br /> .t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT iE <br /> i <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 I� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ,I <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. / !I <br /> Job Address ' City Lot Size f Q Q IIIj <br /> — <br /> r <br /> Owner's Name 4n Phone <br /> Contractor r bress , nse No. Phone_ <br /> TYPE OF WELL/P00 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ IM <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ �I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE . <br /> FOUNDATION AGRICULTURE WELL -OTHER WELL PITS/SUMPS <br /> '- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well',Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public ❑ Other ; A Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.-Approx. Depth I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State'Work Done <br /> Well Destruction ❑ Well Diameter 1 �Sea ling-Material_{top 50'1 <br /> Depth ✓ Filler Material IBeI 1 ° nNk <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO 'l.] REPAIR/ADDITION t D STRUCTION l I Wo septic system permitted if public sewer is <br /> available within 200 feet.i v <br /> I Installation will serve: Residence ZCommercial_-Pther <br /> Number of living units: —],-- Number of bedrooms <br /> Character of soil to a depth of 3 feet: -- ----- r' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg,. +Capacity 000 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Dis osal <br /> ,II cp <br /> Distance to nearest: Well FoundationProperty Line i!" <br /> LEACHING LINE ❑ No. & Length of fines V .Total Iength/size <br /> FILTER BED ❑ Distance to nearest: Well e) Founda"tioA Property Line <br /> SEEPAGE PITS ( I Depth A. <br /> f Size f Number _� I <br /> SUMPS Ll 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 Di1trict, II <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." ContractoYs 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." i <br /> I <br /> The applicant us all for all ra it d inspections. Co fete drawing on revers de. <br /> a <br /> Signed Title: Date: " <br /> FOR DEPARTMENT USE ONLY _ �M <br /> Application Accepted by L/// 7 •• Date' / r r Atea <br /> Pit or Grout Inspection by Date Final Inspection by I' Date <br /> ' Additional Comments: '� 7op - L• .. <br /> Ili �I <br /> ❑ Stk 466-6781 ❑ 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 S t- <br /> yyss j G <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4DFEE <br /> t <br /> CK 9 <br /> 'INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE 11 11'NO. <br /> �.EHt3-24F1REV.V Ks! _ <br /> EH 14-2e ( : J <br />