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!d <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> l <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.5494or sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> r Local Health District. <br /> Joh Addresses /Il -,�� ,� � <br /> City G•)'Lot Size G PM <br /> Owner's Namo�, � Address C/­;A Phone is ` <br /> _et <br /> Contractor Address License No. Phone <br />' TYPE OF WELL/PUMP: NEW WELL ❑ fw':, WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTAL N ❑ ; SYSTEM REPAIR 0'_ <br /> OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK=TANK-L____.-.- SEWER LINES DISPOSAL"FLD, PROP. LINE <br /> FOUNDATION RICULTURE WELL OTHER WELL . PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION IONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T of Casing Specifications <br /> ❑ Public ❑ Other # e to Depth f Grout Seal- Type of Grout <br /> ❑ Irrigation _Appro pth :❑ Eastern. Surface S Installed by-- <br /> Repair <br /> y -Repair Work Done ❑ Ty ump H.P. T State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 501 <br /> t <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION ❑ DESTRU7�"`ilable <br /> septic'system permitted if public sewer is <br /> within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> { , <br /> Character of soil to a depth of 3 feet: Water table depth 0 <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 /> rt <br /> FILTER BED 171Distance to nearest: Well Foundation Property Line CV r <br /> SEEPAGE PITS ❑ Depth l 1 j SizeI <br /> Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ! <br /> 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. aril <br /> l, <br /> 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 applicala must call for all re ire, inspections. Complete drawing on reverse side. <br /> Sign y <br /> Title: (�(/V Date: <br /> I FO EP RTME USE ONLY r <br /> � . <br /> Application Accepted by +�''-'�- Date � Area <br /> Pit or Grout Inspection by ` { Date Final Inspection b Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 iff Lodi -3621 ❑ an ca 04 ❑ 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 <br /> EH 1426 � �,�•. -7,� <br />