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I APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IM le P, ✓ 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209} 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f Comp <br /> plete in Triplicate),,,, <br /> ,. <br /> �. • <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 /> Local Health District. <br /> made compliance with San Joaquin County Ordinance No:549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Job AddressZ� <br /> city Size PM <br /> Owner's Name /' <br /> Address <br /> Phone <br /> Contractor p t t <br /> Address <br /> TYPE OF WELL/PUMP: License No: � Phone., a. <br /> NEW WELL Q WELL REPLACEMENT ❑ "1*DE$TRUCTION ❑ <br /> sPUMP INSTALLATION ❑ SYSTEM REPAIR �" i <br /> DISTANCE TO NEAREST./[§EPTIC TANK a OTHER ❑ O <br /> SEWER LINES �" 11DISPOSAL FLD. <br /> FOUNDATION PROP. LINE <br /> AGRICULTURE WELD OTHER WELL <br /> INTENDED USE TYPE'OF WELL PROBLEM!AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> ❑ Industrial ;O'Open Bottom ❑ Monte T ' <br /> Domestic/Private � Dia.-•ot-Well-•Excavation i <br /> EJ'Gravel Pack Dia. of Well Casing <br /> f ❑ Public ❑ Tracy -Type of Casing j <br /> ❑ Other _ Specifications <br /> ❑ Irrigation ❑ Delia —"'=Lldepth of Grout Seal `�` <br /> —Approx. Depth 'n Q East em 4� . ` Su W9.Seal Installed by ' i Type of Grout <br /> r Repair Work Done 1K Type of Pump <br /> H'P` State Work Done <br /> Well Destruction Destruction Well Diameter G <br /> Sealing Material)tO0,50.1; l 1 <br /> Depth y z Imo! <br /> FiberMateriai <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public s <br /> n <br /> • Installation will serve: Residence` Commercial Other r'� <br /> available within 200 feet.) ewer is <br /> Number of living units: Number of bedrooms <br /> } <br /> Character of soil to a depth of 3 feet:. <br /> SEPTIC TANK ❑ Type/Mfg Water table depth j <br /> PKG. TREATMENT PLT. ❑ Capacity i 1 No. Compartments ' <br /> z. Distance to nearest: Well Foundation Method of Disposal <br /> Property Line <br /> LEACHING LINEr I i _ <br /> � ❑�'�No:& Length�of lines <br /> FILTER BED ❑ Distance to nearest: Weil Total length%sie '. <br /> Foundationproperty Line <br /> SEEPAGE PITSr F <br /> ❑ Depth Size <br /> SUMPS ❑ Number' I � <br /> Distance to nearest:- Well <br /> DISPOSAL PONDS Foundation Property Line <br /> I he certify that I have prepared this application and that the work will be done in accordance wi�h�San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> lt � <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> employ any person in such manner as to become subject to workman's compensation laws of 'Contractor's hiring or sub contracting signature <br /> California, permit is issued, 1 shall not <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shal€`empioy persons subject to workman's compensa <br /> tion laws of California."llowi <br /> The applic u t call for all requ mspec s. Co ate drawing on reverse side. <br /> Signed X <br /> Title:' <br /> € Date: <br /> FOR DEPARTMENT U5E ONLY <br /> Application Accepted by '; 2 r� U <br /> Date J �r" Area r <br /> Pit or Grout Ins I <br /> pectin b Date------ <br /> Final Inspection by 11 7 Date f <br /> Additional Comments: � - � ' � , <br /> ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. B{x 2009, .,5tkCA 95201 <br /> '' ) <br /> - F7FEE <br /> /NFO AMOUNT DUE t`w'. AMOUNT REMITTED t CK. <br /> • t 9 CASH 'f.�. - -RECEIVED BY ATE <br /> _ D PERMIT'N0. <br /> + EH 13-24(REV,sins} -- - - _ T-3►..-.... .,; 1y,;,.,,- u — - <br /> EH-14-20 <br />