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F <br /> *!' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I <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 /> Applica for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made compliance with San Joaquin County Ordinance No.549 <br /> Local Health District. G ' <br /> Cit <br /> tl <br /> y -�TLot Size PhPM <br /> �('KJob Address <br /> Owner's Nam <br /> ddress one <br /> r License No. Phone <br /> �ConEractor���r Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM RE AIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER L ES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULT E WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C RUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia o Well Excavation <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T pe of ing Type of Grout <br /> I'3 Public F Other f-1 Delta epth of Gro Seal - <br /> I i Irrigation --Approx. Depth l I Eastern Surface Seal Insta d by <br /> Repair Work Done ❑ Type of Pump H.P tate Work Done <br /> Well Destruction O Well Diameter aling Material stop 501 <br /> Depth Filler Material iBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION aNailabptic system <br /> ithin m rented if public sewer is <br /> 'j <br /> eetl <br /> Installation will serve: Residence, Commercial— Other b <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 "C1 <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size — Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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: 111 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 10 workman's compensa- <br /> tion laws ifomia." <br /> The appli an m st call for alt r d i mplete drawing on reverse side. Q <br /> r, Date: t�r <br /> KSigned X i Title: <br /> F0. DEPARTMENT USE ONLY <br /> Pate c2 6 /0 Area �j ) / <br /> Application Accepted by / ULD <br /> Pit or Grout Inspection by -y / Date Final Inspection by ���` Date�� <br /> Additional Comments: ym1 f / 3 K' y� 1 U <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manta a 823-7104 L3 Tracy 835 6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE `AMOUNT REMITTED CASH <br /> INFO t �!f /p ! <br /> + EH 1324(REV.5/rr 57 ', Q+p'f <br /> EH 14-26 <br /> I <br />