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1 <br /> 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 /> 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. /� p �" �yl- <br /> Job Address <br /> S/ � ' f/ ` /V � U S /CC's- City V V 6 _ ot Size PM <br /> Owner's Name hb lJl S / C/ 14_? /Adtir/� 4 "16/ Phone Phone �Z-'��D <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ��_OI# <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES L FLD. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS r-- <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ElGravel Pa ❑ Tracy Type of Casing Specifications <br /> El Public El El Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ----Approx. Depth E1 Eastern Surface Seal Installed by <br /> Repair Wor Private <br /> ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 „ <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: 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 <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 <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 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 /> 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 must call for all requ red inspections. Complete drawing on reverse side. <br /> Title: <br /> L� <br /> Signed X Z Title: �° �1 Date: 1 r(o -K) <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date � Area O <br /> Pit or Grout Inspection b ` Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 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 /> FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EH 13-24(REV.1/85) 3� eU <br /> EH 14.28 ✓✓✓ <br />