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a <br /> ,. APPLICGATIOI1t FOR PERMIT <br /> lt; SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA .S <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is he+eby 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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> j r <br /> Job AddressCity Lot Size PM <br /> Owner's Name Addressr Z- <br /> Phone <br /> Coniract,s � �Addres License Pho <br /> TYPE OF WELL/PUMP: NEW WELL Il WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. <br /> FOUNDATION AGRICULTURE WELL OTHER W PITS/SUMPS <br /> INTENDED USE n TYPE OF WELL .PROBLEM AREA ... CONSTRUCT ClFICATIONS <br /> ❑ Industrial ,❑ Open Bottom 4 ❑ Manteca ell Excavation Dia. of Well Casing , <br /> ❑ Domestic/Private Cl Gravel Pack 6 ❑ Trac Type of Casing' Specifications <br /> E'1 Public t ❑ Other elta Depth of Grout`�eal Type of Grout <br /> I IrriQatian _..Ap epth I ] Eastern Surface Seal Installed by-��' <br /> c <br /> Repair Work Done ❑ e of Pump H.P. State`Work Done <br />' Well Destructio ❑ ' Well Diameter Sealing Material {top 50'I <br /> Depth Filler Material {Below 50'), ►r I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION 13 DESTRUCTIO ° {No septic system permitted if public sewer is <br /> } vailable within 200 feet.) I <br /> Installation will serve: Residence— Commercial— Other '" "- <br /> Number of living units: Number of bedrooms 'y <br /> Character of soil to a depth of 3 feet: ' = Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Ca pacity No. Compartments <br /> PKG. TREATMENT PLT.'❑ Method of Disposal <br /> 'Distance to neatest: Well Foundation Property.Line <br /> i <br /> LEACHING LINE ❑ No. & Length'of lines— -- - A � -- •. �--r. <br /> 9 Tota! length/size <br /> FILTER BED ❑ Distance to nearest: Well .'Foundation ! - Property Line + <br /> �. .�_._._ .rte...... <br /> SEEPAGE'PITS°' !•I Oepth d Size _ Number + <br /> SUMPS Cl Distance to nearest: Welt Foundation Property fine <br /> DISPOSAL PONDS ❑ J V <br /> hereby certify that I have prepared this applicatiom 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 Diltrict. ,.. r <br /> Home owner or licensed agent's signature certifies the following: "I certifyzthat.in the performance of the work for which this permit is issued, i shall not h <br /> employ any person-in:stich manner as to become subject to workman's compensation laws of California."Contractors 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." I <br /> The applicant m t call for all required i pecti S. Complete drawing on reverse side. 1 <br /> Signed 't Title: <br /> Date: " <br /> ! <br /> FOR_DEPARTMENTU,SE_ONLY_,s,,.� <br /> Ap i ion Accepted by <br /> Date r O Area <br /> r Q ; <br /> Pit or Grout Inspection Y ction b t' �� ate S' 'k <br /> Final Inspection by date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 J ❑ Manteca 823-7104 ❑ Tracy 835-6385 L ' <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 CAH <br /> RECEIVED BY PATE PERMIT NO. <br /> +,SH13-24tHEV.i/n51 — -.01_47 Ll <br /> / /_-7-0 <br /> EH 14-26 <br />