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Zm <br /> APPLICATION FOR PERMITZ <br /> 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 t <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 /> L <br /> Job Address j = City Lot Size PM <br /> Owner's Name Address � x�f 7 l )/ l J Phone <br /> Contractor Address I�cSZc�/E�l( . License No. Phone — <br /> TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT>t DESTRUCTION 9 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR [I OTHER ❑ � " <br /> " DISTANCE TO NEAREST: SEPTIC TANK' 100 SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL. <br /> OTHER WELL=_._PITS/SUMPS-- <br /> INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation a Dia, of Well Casing <br /> Domestic/Private Gravel Pack �; ❑ Tracy Type of Casing 01Z Specifications \\ <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal � \l\Vll <br /> Type of Grout U <br /> ❑ Irrigation ---Approx. Depth ❑ 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 /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal : <br /> Distance to nearest: Well Foundation Property Line c <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 /> w SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that 1 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 following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's 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 applic nt st call for all requi ed insp ions. Complete drawing on lehprse side. <br /> Signed2 611— J` <br /> Title: Date: Y <br /> R EPARTMENT USE ONLY <br /> Application Accepted by Date_ d V� Area <br /> //�� r <br /> Pit or,Gro,et Inspection by atea S 7 Final Inspection by L� Date <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 955201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K <br /> INFO RECEIVED BY DATE PERMIT'NO. <br /> + EH 1 (REV.1/'a s l <br /> EH 144-2826 <br /> J <br />