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i <br /> APPLICATION FOR PERMIT <br /> + SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'f 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 /> Locale Health District. ,. <br /> r <br /> � �. F' � City • Lot Size_ �C qC _ PM <br /> Job Address <br /> Owner's Name Address 2 L � FRe� t Phone <br /> — — 'l`d t� - <br /> Address License No. ~ Phone_ } <br /> Contractor 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM EPAIR ❑ OTHER ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER 1NE5 <br /> LL OTHER WELL ?ITS/SUMPS <br /> FOUNDATION AGRICULT E <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C TRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial L1Open Bottom ❑ Manteca ia. of fl Excavation <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Cas Type of Grout <br /> FI Public ❑ Other ❑ Delta Depth of Grout al <br /> I Irrigation Approx. Depth l I Eastern 5urface.Sea1 Instalie y —_— <br /> P S e Work'Done <br /> Repair Work Done ❑ Type of Pump I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> r <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION I I DESTRUCTION I I availableseptic <br /> wihin 200 feet.)1edif public sewer is <br /> ° <br /> l ✓ � <br /> Installation will sere: Residence,) Commercial— Other fY1 r91rir�. <br /> Number of living units: I Number of bedrooms Lf0 t <br />'i � Water table depth <br /> Character of soil to a depth of 3 feet:.k �'` <br /> �6 n.C�-� _ Capacity /2430 No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: well Foundation Property Line_ASO <br /> AV <br /> Tot I le gth/size <br /> LEACHING LINE CI No. & Length of lines OC1 <br /> n <br /> I FILTER BED ❑ Distance to nearest: Well Foundation roperty Line <br /> } <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS 0 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 Diltrict. <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."alContractor's hiring c 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." s <br /> The applicant must call for all required inspections. omplete drawing on reverse side. <br /> k Signed X <br /> Title: © - Date: <br /> FAR DEPARTMENT USE ONLY <br /> I _ Date ' <br /> Pit or Grout Inspection by <br /> ' Application Accepted by <br /> i <br /> Date Final Inspection b Date3`� <br /> Additional Comments: <br /> r ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑ Tracy 835.6385 <br /> I95201 <br /> Applicant--Return all copies to: Environmental Health Permit/services 1601 E. Hazelton Ave., P.4. Box 2009, Stk., CA <br /> CK RECEIVED BY DATE <br /> INFO PERMIT NO. <br /> FEE OUNT DUE AMOUNT REMITTED CASH <br /> +.EH 13-24{REV.I <br /> EH 14-26 V <br />