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i <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 TYEAR 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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. . <br /> City f of Size PM <br /> Job Address'� / yy <br /> - Phone v <br /> Owner's Name <br /> s L-1— <br /> hone <br /> Contractor � nse No. P <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <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 ,y <br /> I'1 Public ❑ Other ❑ 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 0 Well Diameter Sealing Material [top 50') <br /> t Depth Filler Material elo ) <br /> f8 -- <br /> TYPE OF SEPTIC WORK: ,,NEW INSTALLATION 11 REPAIR/ADDI;ION KDESTRUCTION l I (No septic system permitted if public sewer is <br /> f <br /> available within 200 feet.) <br /> w 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 ❑ Type/Mfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ / _ Method of 17�fat <br /> Distance to nearest: Well Foundation __ Property Line .S L— <br /> d <br /> LEACHING LINE ❑ No. & Length of tines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> PAGE PITS I I Depth Size <br /> SEE Number - <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 Di%trict. <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 10 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 t 1 or squire i spections. Complete drawing on revers side. o <br /> � Signed X <br /> Title: C Date: <br /> FO NLY [� <br /> Application Accepted byCQI� Date �^ v Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INF (�July f� /J <br /> �.EH 13-24 IREV. /N 51 D!� '�+tf V V <br /> EH 14-26 <br />