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rr <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON; CA . x <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 Ordinan No. 9 for se+mage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 7 // y <br /> Job Addrt'c="` i City Lot Size PM <br /> _ ..- <br /> oyiOwner's Name Address Phone <br /> Contractor ress L icense No. Phon <br /> TYPE OF.WELL/PUMP: NEW VkTA L ❑ µ WELL REPLACEMENT ❑ r DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ f { 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. El Tracy Type of Casing - - - Specifications <br /> F1 Public f7 Other Cl Delta Depth of Grout Seal Type of Grout <br /> € 1 Irrigation Approx. Depth I I 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 50'1 <br /> Depth Filler Material (B to 'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E:I REPAIR/ADDITION r DESTRUCTION I'.) INo septic system permitted if public sewer is �- <br /> available within 200 feet.) , <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: A_ Number of bedrooms L <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK E.7�Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �Q} Method of Disposal <br /> Distance to nearest: Well r1y Foundation Property Line <br /> - : <br /> LEACHING LINE . ❑ No. & Length of lines _ Total length/size <br /> FILTER BED ❑ Distance to nearest:p Well�� Foundation Property Line <br /> SEEPAGE PITS [ 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> 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, l shall not <br /> employ any person iii 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 compensa- <br /> tion laws of California." J3 <br /> The applican must c or all a u' d i s tions. Complet rawing verse side. <br /> / r <br /> 1 --� // y <br /> Signed X Title: 4Date: <br /> FOR DEPARTMENT USE ONLY,i <br /> Application-Accepted by \ �� Date S __. Area `` d <br /> �— <br /> Pit or Grout Inspection by Date ,:�Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369- 1 O Manteca 823-7104 ❑ 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 /> CK FEE_ INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT{NO. <br /> ♦ EH 2 (REV.rirssy W e S� fiS ��L6 <br /> IC <br />- EH 1428 <br />