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.T733 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZELTON 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 /> .lob Address � �City _ Lot Size PM <br /> Owner's Name �dr�ess� d Phone yo <br /> Contractor's Name License No./1P y l Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 9--" 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 /> 2'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Dh ❑ Eastern urface Seal Installed by r <br /> Repair Work Done it Type of Pump r H.P. State Work one <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 �0 <br /> Depth Filler Material Below 501 (- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION,❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> F available within 200 feet.) Z <br /> Installation will serve: Residence_ Commercial_ Other + <br /> Number of living units: Number of bedrooms h: 1 <br /> Character of soil to a depth-of 3`feet: - `"� '. "" - Water table depth ) <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Q <br /> PKG. TREATMENT PLT. ❑ Method of Disposal [ <br /> Distance to nearest: Well Foundation Property LineVI <br /> " <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth. .. .Size Number <br /> SUMPS ❑ Distance to nearest: Well ` Foundation Property Line <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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the fallowing: "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:"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 /> tion laws of California." <br /> The applican st II for al re ed inspectio . Complete drawing verse side. t <br /> Signed X is. Al Date: Z <br /> FOR DEPARTMIIEN SE ONLY <br /> Application Accepted by } Date 3�� Area <br /> 7 <br /> Pit or Grout Inspection by Date Final Inspection by DateA <br /> I Additional Comments: -- <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 , <br /> I 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 /> l + EH 13-24(RFV.101891 . Q� -¢� g" SS-es-3 <br /> IF EH 1426 <br />