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r <br /> j <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 9 <br /> "Telephone (209) 466-6781 -, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) t. , <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. y <br /> Job Address `:1 ! t V\J�l City Lot Size" P1UI <br /> 'l, 1 <br /> Owner's Name _ 't-a Address" T _ Phone - -- <br /> Contractor Vel y L _ Address 0 License No. cr Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 } <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FID. 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 /> .°❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <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 Itop 50'1 <br /> Depth F'ller Material (Below 501 <br /> TYPE OF SEPTIC'WORK: NEW INSTALLATION AIR/ADDITION ❑ DESTRUCTION ❑ (No Septic system permitted if public sewer is <br /> avail ble within 200 feet.) <br /> t <br /> Installation.will serve:�- Residence Commercial— Otherf ) -� 1 <br /> Number of living units: ,v Number of bedrooms <br /> f <br /> Character of soil to a depth of feet: A - Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.: Method of Disposal f <br /> � a <br /> Distance to nearest: Well"_; Jr� � <br /> { . Foundation 0SA Property Line <br /> LEACHING LINE �E!I­�-No. & Length'of lines S Total length/size <br /> FILTER BED ❑ Distance to nearest: " Wel! Foundation + Property Line 1 <br /> SEEPAGE PITS"t 8�hepth Size Nupber <br /> SUMPS , L Distance to nearest: - Well Foundation Zig _ Property Line <br /> DISPOSAL PONDS,,;,- [-] 1 ,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 following: "I certify that-in the performance of the work for which this permit is issued, I shall not i <br /> Mmploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I <br /> ce' " s 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 law f California." <br /> E i <br /> Th applican us all for all eq�ed actio . Co late drawing on r verse std i <br /> Signed Tit - r Date: <br /> - ( I <br /> FOR DEPARTM NT USE ONLY ` <br /> Application Accepted by - Date Area <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments: L✓ Yb G' <br /> ❑ <br /> - Stk T466-6781 Lodi 369 362.1_,__ 823-7-104--g Tracy_I 36-635" �--teoa '- - <br /> , <br /> Applicant- Return all copies to: Environmental HealtFi Permit/Services 1601 E. Hazelton-Ave., P.O. Box 2009, Stk., CA 95201 <br /> Lw I< <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH13-24 1REV.I/x 57 <br /> EH 14-28 <br />