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APPLICATION FOR PERMIT <br /> r -wi ,. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTd� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA No X0 <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. IB62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> L -7511_ �a5 L PM <br /> Job Address <br /> • City -1 �� Lot Size_ - , <br /> 11-eA �� <br /> Owner's Name <br /> { Address �- Phone <br /> Contractor_-_ �'�.— <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' <br /> PUMP INSTALLATI ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> POSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL MAR CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom Cl Ma Dia. of Well Excavation <br /> T e of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type g Type of Grout <br /> —_— <br /> Il Public ❑ Other ❑ Delta Depth of Grout Seal = <br /> I I Irrigation --Approx. Depth I I Eastern urface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Materia op 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPARVADDITION l I DESTRUCTION INo septic sy t m perented if public sewer is <br /> Installation will serve:' Residence— Commercial— Other } <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line r�1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line. <br /> SEEPAGE PITS l I Depth Size Number <br /> k SUMPS LlDistance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared ve re ared 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, I 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 applican _must call for all required <br /> orall-required inspections. Complete drawing on reverse side. �/ a <br /> Signed X » ✓ �� Title: __��JJ`` n Date: + -AD — <br /> R DEPARTMENT USE ONLY i=�= <br /> Date o <br /> Application Accepted by p^7 <br /> Pit or Grout Inspection by <br /> Data Final Inspection by Date�1 / <br /> Additional Comments: <br /> ❑ Silk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 <br /> 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 <br /> a EH 13-24(REV.t/n 51 <br /> EH f4-2B <br /> i <br />