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r? <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZ5L ON AVE., STOCKTON,CA <br /> Teleptzohe (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the Sari 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. f - <br /> Job 6 <br /> 3 �(() <br /> Phone <br /> Lot Size PM <br /> Addres <br /> Owner's Name <br /> I Contractor ice <br /> ddress J / _ Lnse No. Pho __ Q�� <br /> TYPE OF W_E_LL/PUMP: NEW.WELL 11WELL REPLACEMENT LJDESTRUCTION EI <br /> - PUMP INSTALLATION `�-"-- _9YSTEM tPAIR ❑ ---~-- OT-HER <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISF`1 SAL FLD. PROP. LINE. � '! <br /> FOUNDATION AGRICULTURE LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO STRUCTION SPECIFICATIONS , VIA <br /> ❑ Industrial ❑ Operi Bottom ❑ Manteca ia. of WeWEx a ati-r on '-Dia. Well Casting <br /> '❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casi Specifica ons ` <br /> if-I Public Cl Other Cl Delta Depth Jof Gout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface goal Installed by - <br /> Repair Work Done ❑ Type of Pump H State Work Done <br /> 1 Well Destruction ❑ Well Diameter ealsng Materia1'ltop 501 <br /> i Depth ZFiller'lMaterial (Below 50'1 *� <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADNTION I i ESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> r <br /> Installation will serve: Residence_ Commercial Other �• <br /> ' Number of living units: Number of bedrooms <br /> t Character of sol! to a depth o 3 feet: s Water table depth �� <br /> SEPTIC TANK ❑ T pe/Mfg J e Capacity',.-- No. Compartments <br /> PKG,y,TREATMENT PLT. ❑ I 1 { . r Me d Disposal <br /> ; <br /> stance to nearest: Well �Ec, ,talion P_oeryLine <br /> 1 M� LEACHING LINE ❑ Jo. & Length of lines otal leggth size-t— 1 y <br /> t FILTER BED ❑ istance to nearest: Well Foundation Pr arty Line <br /> i n i <br /> i <br /> t 1 <br /> SEEPAGE PITS I I- Depth SizNumber� <br /> SUMPS ❑ Distance to nearest: Well � )P.Fou dation � Property Line <br /> r . <br /> f <br /> DISPOSAL PONDS <br /> ! I hereby certify that I have pre red this application and that the work will betdone in accordance with�San Joaquin county ordi�ances,)state laws, and <br /> rules and regulations of the Sa Joaquin Local Health Di§trict. f 1 <br /> i Home owner or licensed agent' signature certifies the following: "I certify that in the performance of tl�e work for whi h this permit is issued, I shlall not <br /> employ any person in such man er as to become subject to workman's compensation laws of California.a" Contra&8r's iring or sub cont acting signature <br /> certifies the following:"I certify at in the performance of the work for which this permit is issued, I shall employ AriAn subject to workman Wcompensa- <br /> tion laws of California." jf <br /> I The applicant ce r all re wr in tions. 9&nplete drawing on reverse side.` <br /> Signed X <br /> e; Date: /Q O <br /> i 144.1 <br /> FOR DEPARTMENT USE ONLY 1 f J <br /> Application Accepted by Date Area <br /> Date Final Inspection by bat <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> .❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED CW 410 RECEIVED'BY DATE PERMIT' <br /> INFO <br /> +.EH 13-24 IREV.-i I n 51 <br /> EH 14-28 r �� - <br />