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r <br /> i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL ION AVE., STOCKTON, CA <br /> Telephone(209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />'i (Complete in Triplicate) <br /> Application <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 /> unty Ordinance No.549 for sewage or No. 1862 for well/Rump and the Ryles and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Co <br /> Local Health District, ry r <br /> Clty "Lot Size PM <br /> Job Address <br /> Phone' --� <br /> Owner's Name ` ddress s ` <br /> Contractor <br /> PU ✓Address_ � �NEW WELL ❑ WELL REPLACELicense N �D Phone �\ <br /> TYPE OF WELL/ MP: MENT 13DESTRUCTION LJ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE �) <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL .PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> �. - <br /> Domestic/Private ❑ Gravel Pack [3 Tracy Type of Casing Specifications <br /> ti <br /> ❑ Public <br /> ❑ Other ❑ Delta Depth of Grout Seal ►°., Type of Grout <br /> � , <br /> ❑ Irrigation JApprox. Depth Eastern Surface Seal Installed by f f <br /> Repair Work Done Type of Pump H.P. State Work Done V <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 -- q <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION ❑ (Noavasble�wt She200 fe fitted if pubic sewer is <br /> LL�.r�� , <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number 6f`bedrooms'- <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> 1 :.Capacity �� No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg k <br /> `' a .►.� '• ` A"q ^� Method of Disposal <br /> TREATMENT PLT. ❑ � � '"� <br /> Distance to nearest: Well Foundation Property tine <br /> LEACHING LINE ❑ No. & Length'of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> Size Number <br /> SEEPAGE PITS ❑ Depth r. <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS E3 <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 <br /> 1 rules and regulations of the San Joaquin Local Health District. <br /> t 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 <br /> certifies the following:"I certify that in the performance employ persons stibject'to'workman's oNo pensa <br /> of the work for which this permit is issued,I shall <br /> tion laws of California." ` <br /> Thie'applicarcNst cal for all q ve .6P46-tions. Complete drawing on rev a side. <br /> Signed <br /> Title 4�J Date: <br /> FOR DEP TMENT USE ONLY <br /> .� -8 6 <br /> .JArea <br /> Applicatio Accepted by Date ! <br /> Date' Final Inspection by <br /> Pit or Grout Inspection by <br /> J Date 1 U <br /> f <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 1� ❑ Manteca '823-7104 ❑ Tracy <br /> P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601'E. Hazelton Ave., <br /> yj <br /> r ! <br /> FEE AMOUNT bUE AMOUNT REMITTED RECEIVED BY DATE. PERMIT'NO. <br /> INFO 1 t <br /> '.+ EH 13-241REV.1/851 �, Q� <br /> EH 1426 - <br />