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r <br /> APPLICATION FOR PERMIT' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON', CA Np <br /> Telephone (209) 466-6781 N0 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ". �' f <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. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> 13-4 vFde-? City S/4- <br /> > Lot Sire Pl1/I <br /> Owner's Name - �� Address Phone <br /> CuntractoF' Jif Address ✓ -License No hone fn y�fv <br /> TYPE OF WELL/PUMP: NEW WELL ❑. . WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION q SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPT SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION - AGRICU <br /> 0—­PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO TION SPECIFI <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of-Well Casing <br /> ❑ 'Domestic/Private ..❑ Gravel Pack ❑ .,_ Type-of.Casing Specifications <br /> M Public ❑ Other ❑IDelta Depth of Grout Seal Type of Grout _ <br /> I 1 Irrigation .-App Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ T of Pump t H.P, \ <br /> t State Work Done_ <br /> Well Destruction Well Diameter Sealing Material (too-50') <br /> Depth Filfer Material (Below 501 ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.l REPAIR/ADDITION i I DESTRUCTION I (No septic system permitted if public sewer is <br /> 4 ' 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 <br /> r Water table depth <br /> i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ F 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 r ` <br /> SEEPAGE PITS I I Depth Size Numberr <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C7 ` <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 d <br /> rules and regulations of the San Joaquin Local Health District. —­r -{ d <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 I <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 applic ust call for all equir d nspections. Complete drawing on reverse side. <br /> I <br /> Signed Title: 7 i <br /> Date: t <br /> t <br /> FO ENT.USE ONLY j <br /> Application Accepted by r IA Date_ Area ~ <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: _- <br /> C1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 8Y DATE PERMIT'No. <br /> INFO AS}t <br /> r EH13-24(REV.1/x51 <br /> EH 14-2e IJi <br /> r <br />