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- S <br /> I <br /> APPLICATION FOR PERMITf' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA ` <br /> 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 /> Local Health District. ' <br /> ii <br /> Job Address CO ae- City��Lot Size PM l <br /> �� <br /> Owner's Name Address Phone <br /> i! <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ ! ,/ <br /> PUMP INSTALLATIO ❑ SYSTEM REPAI ❑ OTHER ❑ 1 s <br /> DISTANCE TO NEAREST: SEPTIC —+�— SEWER LINES =— DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION RICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTa6cTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing <br /> n'Domestic/Private ❑ Gravel Pack ❑ Tracy T e o sing Specifications j <br /> F1 Puhlic I ❑ Other ❑ Delta epth of Grou I Type of Grout _ <br /> k I Irrigation ..Approx. Depth l I Eastern Surface Seal Installed b _ <br /> Repair Work Done ❑ Type of Pump H _ State Work Done i R <br /> Well Destructions ❑ Well Diameter Sealing Material {top 50'► ` <br /> 1 Depth Filler Material (Below 501 . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l.1 DESTRUCTION (No septic system permitted if public sewer is j <br /> available within 200 feet.? <br /> Installation will serve: Residence_ Commercial_ Other <br /> { <br /> Number of living units: Number of bedrooms � t <br /> Character of soil to a depth$of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> I <br /> T PKG. TREATMENT PLT. ❑ I tom„1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ 'No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I'I tDepth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line I <br /> DISPOSAL PONDS ❑ i <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 II <br /> rules and regulations of the San Joaquin Local Health District. <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." Contractors hiring or sub-contractingf signature ' <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of Cal- ia.". ..�.� .,..� ...��. ...r.. _e <br /> The applicant us c for a quire spections. CopoWlte drawing on reverse side, <br /> V ; ti e <br /> Signed X Title: ' �KeA_ Date: ` �Z <br /> ,rte i <br /> FOR DEPARTMENT USE ONLY j J <br /> Application ccepted by Date t 2 ° Area D <br /> Pit or Grout Inspection Date Final Inspection by Date ' 3t� <br /> Additional Comments: / /t✓ wsil✓eGe! �d`�'! '� aP <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ anteca 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 /> EE INFO Ai410UN7 pUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO, ; <br /> + EHc3-24 1Ft5V.1/N 51 ~ <br /> EH 14-2e J <br />