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i <br /> t <br /> - e ' <br /> APPLICATION FOR PERMIT <br /> h <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> x 1601 E. HAZEL T ON AVE., STOCKTON, CA <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. c ; <br /> Job Address City Lot Size PM i <br /> Owner's Name Address ee Phone <br /> Contractor r Address xft License 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 FLO. I PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_____2 PITS/SUMPS <br /> INTENDED_USEI t TYPE-OF WELL {(PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom',': -'❑ Manteca Dia. ofWell Excavation Dia. of Well Casing <br /> -M l E •t FF? �. <br /> ❑ Domestic/Private. x 0,Gravel Pack'z � ❑ Tracy Type of Casing-� Specifications <br /> M Public t Iii Other [[ Cl Delta Depth of Grout Seal 4 t � : Type of Grout <br /> I I irrigation _._Approx. Depth I'i Eastern Surface Seal Installed 6 _ <br /> Repair Work Done ❑'~Type of Pump.£ "^•'.'` H.P. State WorkDone <br /> {Well Destruction�f ❑. Well Diameter Sealing Material Imp 50'1 <br /> Depth I Filler Material (Below 501 ' <br /> t <br /> tTYPE OF SEPTIC WORK: NEW INSTALLATION -REPAIR/ADDITION l'I DESTRUCTION l I Wo septic system permitted if public sewer is t <br /> available within 200 feet-1 r <br /> d <br /> � Installation will serve: Residence.� Commercial''Other ��' "� c • Y, � <br /> .y Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: i ; 'Water table depth ` F <br /> ` SEPTIC TANK K" Type/Mfg a� Capacity �+� No. Compartments <br /> PKG. TREATMENT PLT. El /�. ,, .. Method.of Disposal 1e <br /> Distance to nearest: Well Foundation o4.� _ Property Line �V <br /> x <br /> e ,.;r <br /> LEACHING LINE L'r -No. & Length of lines t Tatal lengthlsize p <br /> FILTER BED ❑ Distance to nearest: Well Foundation ' "' ""- Property Line <br /> 1 SEEPAGE PITS Depth Size Number i`:" ©,00f" <br /> SUMPS ❑ ist nc to crest: Well Foundation Property Line ! f <br /> ' DISPOSAL PONDS Qr. t / lAl <br /> "1 hereby certify that I have prepared this application and that the work`�III bed in accord ce wit h] a Joaquin unty ordina ces, state laws, and <br /> rules and regulations of the San Joaquin Local Health District- � ,lL�e 9 /°f,/� sr�{ 14 /�fj�� Jw,* � <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance'�iof the work for which this permit is issued, I shall not <br /> i employ any person in such manner as to become subject to workman's-compensation-laws of,California." Contractor's hiring or sub-contracting signature F <br /> certifies the following: "I certify that in the performance of the work for which this permit isissue,I shall employ persons subject to workman's compensa- r <br /> cion laws of California." <br /> The applicant m st call fo all required inspections. Complete drawing on reverse side. <br /> - ------- <br /> Signed X ���� - Tltle: —_ ( d�1 } Date: <br /> t OR DEPARTMENT USE ONLY r <br /> Application Accepted by'' DateArea i <br /> Pit or Grout Inspection.by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca-823=711041-- ❑ 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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED c RECEIVED BY PATE PERMIT"NO. i <br /> .yy . <br /> a.EH 134-26-241REV.1/Ksl ri W (� rr 9 `]Q�� ���(�Q �� <br />