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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE;TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) t <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 i <br /> ,l <br /> Local Health District. �} ( (,'M <br /> City Lot Size <br /> Job Address <br /> Z/f �J <br /> p�/ ��K/ �/� `f L" L �f1V rt✓Phone <br /> Owner's Name A ddress <br /> O(��✓�1'�— Address <br /> Contractor License No. Phone_ <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> OTHER ❑ <br /> PUMP INSTALLATION L1 SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 'OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> y❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy YP g Type of Grout — <br /> (`l Public Cl Other C1 Delta —Depth of Grout Seal <br /> I i Irrigation _Approx. Depth I 1 Eastern Surface Seal installed by <br /> State Work Done <br /> Repair Work Done L3 Type of Pump <br /> H p <br /> Well Destruction ❑ Well Diameter Sealing Material [top 50'1 <br /> ti <br /> Depth Filler Material (Below 501 4 <br /> te <br /> TYPE OF SEPTIC WORK NEW INSTALLATION . REPAIRIADDITION i I DESTRUCTION I I (No septic syst m r fitted if public sewer is <br /> Installation will serve: Residence— Commercial X Other f <br /> Number of'living units: Number of bedrooms Water table depth 7 <br /> Character of soil to a depth of 3 feet: I� U v <br /> Type/Mfg�' r'� �r Capacity / No. Compartments <br /> ! SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT. ❑ /� e <br /> i Distance to nearest: Well &_0 Foundation-r`--=—,Property Line <br /> LEACHING LINE No. & Length of lines — C) Total length/size - <br /> 0 Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Wel <br /> ell a <br /> SEEPAGE PITS [ Depth Number,_.Z Size _ <br /> i L7 Distance to nearest: Well , Foundation `y Property Line " <br /> SUMPS <br /> DISPOSAL PONDS ❑ <br /> that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> hereby certify that i have prepared this application and <br /> rules and regulations of the San Joaquin Local Health Di3trict. <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 /> �. to become subject to workman's compensation-laws-of California." Contractor's.hiring of sub-contracting signature <br /> employ any person in such manner as <br /> certifies the following: "I certify that in the performance of the work for which this permit i5 issued,!shall employ persons subject to workman's compensd <br /> tion laws of California.' <br /> The applicant ust�Calllol �reimd �ns, omp( drawing on reverse side. <br /> Signed X <br /> v Title: ������ Da e: 4 <br /> FOR DEPARTMENT USE ONLY , <br /> Area <br /> Application Accepted by ( Z 1 <br /> Date!Z l / Final Inspection by�` J Date <br /> Pit or Grout Inspection by rQJJ�p�,,,�� <br /> r "`� <br /> r <br /> Additional Comments: - ^ f <br /> i ❑ Stk 466-6781 11Lodi 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 /> FCK' RECEIVED BY <br /> INFO -DATE PERMIT'tUO.� <br /> EE <br /> AMOUNT DUE AMOUNT REMITTED H <br /> rEH13-24iREV.t/nsl �r D• �` l)S� _ „�. V`�—�� �� '��� <br /> EH 14-26 V <br />