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pq,t� <br />e APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 7 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. ae rr{ . r 7&'P <br />{ Cb e rd City l,4 Pf1� <br />I< <br />Job Address <br />it/i O Phone z. <br />Owner's Name A Address -—� <br />Contractor's Name 0License No. Phone <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 Weil Casing <br />❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />❑ Public i ❑ 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 {top 501 <br />i Depth Filler Material (Below 501 <br />TYPE OF SEPTIC WORK: NEW I NSTALLATI ONf,,,R EPAIR /ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will,serve:Ag Residence Commercial _ Other _ <br />Number of living units: Number of bedrooms <br />t� <br />Character of soil to a depth of 3 feet: CL —) ' 1 Water table depth <br />SEPTIC TANK Type/Mfg P Ald L Capacity No. Compartments ?� <br />PKG. TREATMENT'PLT. ❑ Method of Disposal <br />a 4 Distance to nearest: Well _ Foundation Property Line A } <br />LEACHING LINE �Z­ No. & Length of lines Z Total length/size m <br />FILTER BED c� . ❑ Distance to nearest: Well Foundation Property Line <br />SEEPAf2E PITS, J❑ Depth 1 b f'f` Size i Number01 <br />�► <br />� Distance to nearest: Well �_ Foundation Property Line <br />DISPOSAL PONDS ❑.t. <br />L__�L_. — r,A. aL..l '1 .......... . ....J ♦L.7� .. >.I:nei:.... —A that the work .w,e ill hrinne in Rrrnrrianra with San JnRnidn rnuntv ordinances. state laws. and <br />....... ................ <br />rules and regulations of the -Sari 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 mariner 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." - i <br />The app' must call fZr all required.inspectio s. '00rowing on reverse side. <br />i <br />Signed f Title: Date: <br />`a y # FOR DEPARTMENT USE ONLY <br />" `t.... <br />Application Accepted by Date �2��0.-- Area <br />x <br />-"Pii� Inspection by ate X11'OF al Inspection by o Date <br />`Additional Comments: , <br />❑-Stk 466-6781 ❑ Lodi 389-3621 an 823-7104 ❑ Tracy 13145-636c� <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 <br />+ EH 1324 [REV. 101831 <br />EH 14.28 <br />FEE <br />INFO AMOUNT DUE <br />AMOUNT REMITTED <br />CASH . <br />- RECEIVED BY <br />-` <br />DATE PERMIT`NO. <br />J <br />i <br />�1 <br />