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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON,,CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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 Instill 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 flubs and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �ity � Lot Size PM <br /> Owner's Name,? b1 Address=26 SCW CA&+f Phone' <br /> Contractor i40 - Addreu- to No. Phtme <br /> TYPE OF WELUPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTKYIPKW <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE..TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP.LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE-,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation bia.of Won Casing ' <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Public ❑ Other 0 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 <br /> Well Destruction ❑ Well Diameter Sealing Material(top 5(y) 6 <br /> Depth Filler Material:(Below 50 r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system�etm' if public sewer is <br /> available within M feet.( <br /> Installation will server Residence Commercial— Other �} <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 0 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. &Length of lines Total length/size <br /> f iLTER BEV: ❑ Distance to ne4rest, Well Foundation Property Line <br /> SEEPAGE PITS 0 Depth Size Number <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 dorm 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: "I certify that in the perfomrance of the work for which this permit is issued,I shall not <br /> employ any person in such manner as to becomo subject to workman's compensation laws of California.-"Contractor's hirftg orsub-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 II for all rootdred i ons. Complete drawing on reverse side. <br /> Signed Tide: „ T Data: <br /> FOR DEPARTMENT USE ONLY , <br /> Application Accepted by " Date r Ards L✓ <br /> Pit or Grout inspection by Date Firms InVoction by Date b <br /> Additional Common <br /> Stk 466-Ml Lodi 3W3VI ❑ Manteca- SM-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all o ' to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box`=9, S*-,CA NMI <br /> FEE AMOUNT DIFF." AMOUNT REMITTED RECEIVED BY DATE PaMwWo. <br /> INFO CASH <br /> + EH 13-24 EH 11-28(REV.t/a5) ,��`-_ 3S ©p ��Z1� -SSs <br />