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pv <br /> 14 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) <br /> M in described:This a lication is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here pP <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. <br /> t <br /> I Job Address `" l City " Lot Size PM <br /> Owner's Name /I �• ��nddss Phone <br /> Contractor <br /> Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , <br /> PUMP INSTALLATION ❑ -SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE T SEPTIC TANK SEWER LINES DISPOSAL FLD. . LINE <br /> FOUNDATION AGRICULTURE,,WELL OTHE PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TRUCT EGIFICATIONS <br /> ❑ Industrial ❑iOpen Bottom ❑ Manteca Di a ation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ a Depth of Grout Seal Type of Grout <br /> I ❑ Irrigation _ Approx. D ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type ump H.P. State Work Done <br /> I 0 Well Destruction 411 Diameter _ Sealing Material (top 501I. <br /> a. <br /> r -Depth Filler Material'J Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> ilpF available within 200 feet-1 .,Y;. <br /> � 1 <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a dept h'r 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 /> 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 f <br /> SUMPS ❑ ,Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑1 <br /> M 1 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 Sian Joaquin,Local Health District..--.„...._., <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the.perfor'mance 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." Contractors 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 mu call for all required inspections. Complete drawing on reverse side. <br /> 6217 <br /> Signed X I� Title: 0 Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date —Z� Area —02 <br /> Application Accepted by ` <br /> Pit or Grout Inspection by "� Date Final Inspection b Date �,L <br /> Additional Comments: " <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ElManteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copiesrto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE' <br /> AMOUNT REMITTEDRECEIVED BY . DATE PERMIT'NO. i <br /> INFO CnH <br /> i+ EH 13.24(REV.-1-785) �5. .o O 3/� <br /> EH 14-26 'j��� <br />