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~� 44A* <br /> .�!' .ate <br /> FFA APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ONiAVE., STOCKTON, CA <br /> 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.W for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District..:i. a'..3r.� <br /> Job Address jr�/� ��( <br /> ,�.jCity. Lot Size <br /> PM <br /> Owner's Name - Address 7 /� Phone <br /> t Contractor G f Address License Np F <br /> Phone <br /> =TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> k <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 /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> 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 /> 3 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> 3 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> t Well,Destruction ❑ Well Diameter , Sealing Material {top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) l <br /> -'.Installation will serve: Residence_ CommercialrV <br /> Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 4 Capacity No. Compartments <br /> PKG. TREATMENT PLT. F1 - Method of Disposal <br /> Distance.,to nearest: Well Foundation Property Line <br /> E—KC14FNG LINE-- OR Nb7&'Lengthof.iiiies�` <br /> 3otil length/size" <br /> FILTER BED ❑ Distance to nearest: ' Well,�_ Foundation—11!7 Property Line_!_ <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> j.DISPOSAL PONDS ❑ d <br /> I 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 /> h.employ any person in such manner as to become subject to workman's compensation laws of California."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 <br /> tioncompensa <br /> _laws of California." t <br /> The applicant mustcall for all require inspections. Complete drawing on reverse side. <br /> ' Si ned � "f � Title: <br /> tt � <br /> �' �. Date: J <br /> / FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date ' a Area <br /> Pit or Grout Inspection by y Date Final Inspection by D8 <br /> I Additional Comments: <br /> I <br /> ❑ Stk 466-6781 ' 'EY Lodi-369-3621-11 Manteca 823-7104 ❑ Tracy 835-6385 . <br /> c Applicant. Return all copies toe Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK BY DATE PERMIT'N0. <br /> INFO CASH+EH f42d(REV ) EREECEIVYED <br />