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F <br /> i <br /> 00 APPLICATION FOR PERMIT <br /> k. �f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> F 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. f1 <br /> Job Address VV I� [�V <br /> City Lot Size 6 T PM <br /> E Owner's Name V%eira Address 1, Alcofff aC <br /> Phone ✓J <br /> Contractor e Address License No. Phone_ <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f' <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 C <br /> F1 Public ❑ 9ther Ll Delta Depth of Grout SealType of Grout�Q►�C /1Z� \ <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 Sealing Material (top 501 <br /> jDepth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION !1 REPAIR/ADDITION i I DESTRUCTION i 1 (No septic system permitted if public sewer is ` <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> F Character of soil to a depth of"3 feet: Water table depth <br /> SEPTIC TANK EJType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. El - Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r . <br /> I LEACHING LINE ❑ No. & Length of lines Total length/size <br /> I� FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I SEEPAGE PITS I I Depth Size Number <br /> SUMPS LJ 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 la <br /> rules and regulations of the San Joaquin Local Health Diltrict. ws, and <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 of 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 /> 1 tion laws of California." <br /> The applicant st call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: r�"I—� g <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �I Area s <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> c Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> rt Applicant- Return all copies to: Environmental,Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> +.EH 13-24 1REV,1/h 51 a5, <br /> EH 14.26 {/�/ <br />