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APPLICATION FOR PERMIT <br /> j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l 1601 E. HAZELTON AVE., STOCKTON, CA <br /> i Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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 <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 /> F Local Health District. i a <br /> 3b C��1'1S' , City :r Lot Size <br /> Job Address PM <br /> h - - " <br /> 4 Y! // Phone <br /> Owner's Name Address <br /> ` <br /> l � <br /> Contractor's Name License No. 3 Phone (� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE. <br /> i FOUNDATION GRICULTURE W OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL��±PROBL'EM AflFA TRUCTION'SPECIFICATIONS . <br /> ❑ Industrial ❑ Open Bottom 1 ❑ Manteca Dia. of We avation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ? ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Ea rn Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (NosbpticYsh nem emitted if public sewer is <br /> avaInstallation will serve: Residence'L Commercial_ Other <br /> ' Number of living units: /-- Number of bedro ms -- <br /> w 41 Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. F-1let <br /> of Disposal f <br /> t <br /> Distance to nearest: Well Foundation Property Line <br /> "F <br /> LEACHING LINE I No. & Length of fines Total length/size M z 1 <br /> FILTER BED ❑ Distance to nearest! Well Foundation Property;Line, •�a 'fes 1 <br /> SEEPAGE PITS ❑ Depth I Size tom. Number ' <br /> SUMPS Distance to nearest:. Well _ Foundation� Property Line 41-31-0 �J <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 District. <br /> Home owner or Vicensed 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 sucPrnanner as to become subject to workman's com"nsation•laws-of-6alrfornia.-Contractor'"s'hiiing ar sub contracting signature <br /> certifies the following ,'I certify that in,the performance of the work for whlcF this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Ca0or" &.-JO Y v i 3 <br /> The applicant II for 11 required inspections. Complete''dr*awing on reverse side. <br /> Yt Y- "_-:-t '-Date: <br /> Signed -^47�41e: � `�� <br /> FOR DEPARTMENT USE ONLY <br /> Date. rf 6 Area f <br /> Application Accepted by ; 1� pIV <br /> Pit or Grout Inspection by4r Date N't* Final Inspection by uy /T�� � Date=�. <br /> - . , r t ;, <br /> Additional Comments: j { <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Q Manteca 823-7104 ❑.Trapy,835 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> - -4_- �. <br /> FEE AMOUNT DUE AMOUNT.REMITTED ECCA"S RECEIVED BY DATE PERMIT'NO.INFO —4[REV.10/a3F '�EH 1426 <br /> k i <br />