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r <br /> .i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> Ij PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> II (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 /> Job Address 5 City Lot Size PM <br /> E 5 Owner's Name AddressI LA 3Phone <br /> Contract I Address�� r6 ! License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El 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 <br /> ` <br /> 1"1 Public F1 Other F Delta Depth of Grout Seal Type of Grout <br /> ( n I I Irrigation _ -Approx. Depth- t i Eastern Suriace'Seai Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> ' Sealing Material Itop 60'1 <br /> ' <br /> Well Destruction- ❑ Well Diameter 9 <br /> Depth \ r Material I8elow 501 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAI ADDITIO DESTRUCTION I i INo septic system permitted if public sewer is <br /> I <br /> available-witYayn.200 feet:) <br /> f Installation will serve: Residence� Commercial— Other <br /> z Number of living units: /. _Number-of-b Brooms—A ...... <br /> ! Character of soil to a depth!of 3 feet: t i �A�Inr� Water table depth <br /> I SEPTIC TANK ❑ T ype/Mfg) Capacity No. Compartments <br /> I PKG. TREATMENT PLT. ❑ Method of Disposal <br /> i <br /> Distance to nearest: Well foundation Property Line <br /> ! LEACHING LINE No. & Length of lines f "Total length/size �� " <br /> Fll7ER BED ❑ iDistance to nearest: Well 50 Foundation-A-0 Property Line _ <br /> SEEPAGE PITS [ I ,,'Depth Size ' Number <br /> SUMPS L) ('Distance to nearest: Well Foundation Property Line s <br /> DISPOSAL PONDS © I' <br /> 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 to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: ­1 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." G' _ <br /> The applicant m t call f II r quired inspections. Complete drawing on reverse side.. <br /> ' O Q� <br /> I Signed X Title:`"" `_ Date: <br /> 5 <br /> FOR DEPARTMENT USE ONLY ! <br /> •�� /� Area <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date r Final Inspection by ate <br /> Additional Comments: <br /> ❑ 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 95241 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH 1324 IREV.%/R 51 i 5 t..j`-� f_ { l� -V0 <br /> EH 14-28 i ;r ttt tt�� <br /> II rq\L <br />