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i <br /> APPLICATION FOR PERMIT <br /> M SAN JOAQUIN LOCAL"HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <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 instal!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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address t ~�� Ci h�Lot Size PM <br /> Owner's Name&AgAddress 2- Phone A -� - <br /> Contractor Addressf,r -�1 - License No.7� �r Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR_❑ OTHER '< <br /> 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 'FOUNDATION''' AGRICULTURE WELL OTHER WELL PITS/SUMPS h i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> w ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1 Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by I <br /> Repair Work Done )11. Type of Pump _dAd!:!� _ H.P.i State Work Done r �� <br /> Well Destruction ❑ Well Diameter Sealing Material(top-50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is V 1 <br /> ! available within 200 feet.) <br /> I Installation will serve: Residence— Commercial_ Other # ! O <br /> Number of living units: Number of bedrooms <br /> 1 <br /> Character of soil to a depth of 3 feet: '�• ` - '�f ° Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity E_ - l No. Compartments <br /> i PKG. TREATMENT PLT. ❑ � Method of Disposal <br />{I Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ Na. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation •P�operty Line <br /> f SEEPAGE PITS ❑ Depth Size Number€ Z <br /> z <br /> SUMPS _ El Distance to nearest �; Well - Foundation Property Line spy. <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 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."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 must call f II required inspections. Complete drawing on reve side. <br /> Signed Title: Date: 72 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by `�- <br /> /2- L Date Area '! <br /> Pit or Grout Inspection by Date Final Inspection by Date��� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 CC <br /> INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT"NO. <br /> +EH 13-24(REV.1/as) v s,va ^7/ Q� <br /> EH 1426 // 7 —!a R7. V (_AW/ <br />