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f <br /> i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT n 3N; <br /> 1601 E_ HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROW 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin <br /> + Local Health District.' <br /> r Job Addressx..;? City;�`' '� Lot Size PM <br /> r 'J <br /> Owner's Name �/ Phone <br /> – � -Address <br /> / Q Phone -"` <br /> P Contractor ie Address � ice�er N� _ <br /> r <br /> 1I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIOf$tk< <br /> {' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> i1 <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 t Specifications <br /> ❑ Public ❑ Other j ❑ 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 /> Depth t Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> i i % available within 200 feet.) <br /> It r <br /> Installation will serve: Residence— Commercial_ Other T <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK-` Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> � r <br /> I LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth: Size Number <br /> r <br /> SUMPS ❑ 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 signaturecertifies 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 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 to workman's compensa- <br /> tion laws of California." <br /> The applicant st call for all requir ins tions. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> �7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ 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 /> } IFEENFO AMOUNT DUE . AMOUNT REMITTED �- RECEIVED BY DATE PERMIT'NO. <br /> f <br /> H <br /> + E1324(REV,tie5} �� w�]Q <br /> EH 1428 <br /> t <br />