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APPLICATION FOR PERMIT <br /> SAN JOAQUIN <br /> LOCAL HEALTH DIS r� <br /> TRICT <br /> 1601 E <br /> HAZELTON AVE., STOCKTO � - <br /> Telephone (209) 466-6781 , CA <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ;v-fR1- NEAP-7 . <br /> (Complete in Triplicate) �.ti111lIRO•�,� S�RVIC� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described his application r <br /> made in 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 /> Local Health District. pp cation is r j <br /> Job Address <br /> City Lot Size <br /> J� PM <br /> Owner's Name �1 <br /> Address <br /> ContractorPhone/ 73 C. <br /> - <br /> �� <br /> Address re J . <br /> TYPE OF WELL/PUMP: NEW WELL ❑ License Noi � � _Phone�ty- <br /> WELL-REPLACEMENT ❑ DESTRUCTION Li <br /> INSTALLATION 'E [I SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANKOTHER ❑ <br /> FOUNDATION <br /> SEWER LINES _� DISPOSAL FLD. PROP. LINE <br /> ..,�� AGRICULTURE WELL ' <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 1 <br /> ❑ Open Bottom ❑ Man~ taco pia. o{Well Excavation <br /> Domestic/Private ❑ Gravel Pack Dia. of Well Casing t <br /> ❑ Tracy Type of Casing <br /> 11 Public ❑ Other F1 DeltaSpecifications <br /> Depth of Grout Seal <br /> I i irrigation —..Approx. Dept I 1 Eastern Type of Grout <br /> Surface Seal Installed by � ¢ a ' <br /> Repair Work Done ❑ Type of Pump r _ <br /> ------._State Work Done <br /> Well Destruction ❑ Well Diameter _ Sealing Material {top 50') <br /> Depth Filier Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-[] REPAIR/ADDITION I ) DESTRUCTION I I INo septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial Other * available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _. ---- <br /> 'SEPTIC TANK ❑ Type/Mfg Water labia depth # <br /> Capacity No. Compartments I <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1-1 Depth Sizea <br /> 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, 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: "1 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." - w-— - <br /> The applicant st gall for all re iced inspections Complete drawing on reverse side. ] <br /> Signed X <br /> ........... <br /> J tle: I <br /> Date: <br /> FOR DEPARTMENT USE ONLY /` <br /> Application Accepted by Date r " Area <br /> Pit or Grout Inspection by Date Final Inspection by Date & q &,ql <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED 9Y <br /> CASH DATE PERMIT'NO. <br /> r EH 13-I4 IFiEV.I/H 51 <br /> EH 14-28 <br />