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4 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT L <br /> -1 W 1601 E. HAZEL T ON AVE., STOCKTON, CA , <br /> f/1 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." ti <br /> Job Address act �-. City Lot Size Ply <br /> i <br /> Owner's Name d� �. Address Phone <br /> Contractor.---.edress f- 1� License No Phone <br /> TYPE OF WELL/PUMP:? NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ 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 Work Done <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 <br /> 4 available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> ': <br /> Number of living units: Number of bedrodm. s <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 j <br /> Distance to nearest: Well Foundation. Property Line t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS ❑ Depth 1 -S ize 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'Healtli Diitricf:"q''' <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 Califomia." 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 call for all required ins ctions. Complete cawing on <br /> Signed �� _ Ti'le: <br /> Date: <br /> FOR DEPARTMENT USE ONLY ' <br /> Application Accepted by Date " k� Area <br /> ® C�_ ' <br /> ' ee / � s. . <br /> Pit or Grout Inspection Date t5- Final Inspection by_ � Date a' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> k . <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED- CK RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-24 IfiEV. �J" <br /> EH 1428 <br /> 4 <br />