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4 a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ' <br /> I � l <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 /> 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. It <br /> Job Address I� {' City .q Lot Size PM <br /> Owners Name i� �" Address ��+ s ` p' �te Phone <br /> I! -T917AP Phone <br /> Contractor Address =� � License fJo. _._� <br /> TYPE OF WELL/PUMP: i�. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FLD. _ PROP. LINE <br /> FOUNDATION AGRICULTURE d� OTHER WELL TPITB/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS t <br /> 171Industrial F1 Open Bottom teca Dia. of Well Excavation Dia- of Well Casing <br /> 1-1 Domestic/Private 171GIravel Pack ❑ Tracy Type of Casing Specifications <br /> f <br /> I'1 Public 5 Othe f i Delta Depth of Grout Seal Type of Grout -. ; <br /> I I Irrigation 11-Approx. Depth I I Eastern Surface Seal Installed,by k <br /> Repair Work Done C1 Type of Pump' H.P. - State Work Done <br /> i <br /> Well*Destruction ❑ Well Diameter? Sealing Material (top 501 ' <br /> Depth r Filler Material (Below 50') ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence Commercial _ Other <br /> Number of.living units: �'' Number of bedrooms <br /> h Water table depth ! 1 <br /> Character-of.so_il to a depth of.3 feet: ; <br /> SEPTIC TANK ,"❑_Type/Mfg f Capacity No. Compartments-- a <br /> PKG. TREATMENT PLT. ❑ I F Method of Disp 4sal � z <br /> -`J Distance tc nearest: Well Foundation Property Line {a <br /> I LEACHING LINE ❑ No. & Length of lines Total,leng"th/size <br /> i f <br /> I FILTER BED ❑ Distance td nearest: Well Foundation ° Property Line;: <br />} SEEPAGE PITS 11 Depth Size -LL Number <br /> SUMPS ❑ `Distance to nearest: Well Foundation Property Line <br /> k DISPOSAL PONDS ❑ �! 1 <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 /> r. rules and regulations of the San Joaquin'Local Health District. <br /> Home owner or licensed agent's signature certifies 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 /> l 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 m st call for all�requd ins ctions, Complete drawing on reverse ide. t <br /> Signed Title: Date: <br /> t € FOR DEPARTMENT USE ONLY y <br /> ,� € 0 Area <br /> Application Accepted by '� .- .� Date <br /> Pit or Grout Inspection byII �{� Data_"_ Final Inspection by <br /> 1 <br /> Additional Comments: /6f V, A� ; <br /> � <br /> 4 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Menteca 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 /> l <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'ND. <br /> I INFO '• <br /> + EH1324 IREV.1/n 53 ..� _ / 8 <br /> EH 14-26 f. <br /> t �I i <br />