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a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 0 <br /> A 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. 549 for sewage or No. 1B62 for wellipump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address A) Cityll Lot Siz6_ � PM <br /> i <br /> Owner's Name Address Phone <br /> ,. Address d License No. 6Phane "S/0 <br /> Contrar ct <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ a i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ` PROP. LINE f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ElIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications '+ <br /> [1 Public F] Other Cl Delta Depth of Grout Seal Type of Grout <br /> I Irrigation —.-Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump "H.P. - State-Work-Done - <br /> w <br /> Well Destruction El Well Diameter Sealing Material Itop'S0'I <br /> Depth Filler Material W fow <br /> TYPE OF SEPTIC WORK: NEW INSTALLATfO-NFIEPAiFiiN iCilTION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) , <br /> Installation will serve:, Residence Commercial_ Other O <br /> Number:of living units: _/—wNumher..of- drooms- - --•e <br /> Character of soil to a depth of 3 feet. r Water table depth v I <br /> SEPTIC TANK, Type/Mfg ,4 ' Capacity/&Ie No. Compartments <br /> PKG. TREATMENT PLT. ❑ � '! "'�,��r r Method of Dipposal <br /> 01 <br /> Distance to nearest:a,, 'Wel]i !_ Foundation to Property Line <br /> LEACHING LINENo. & Length of fines Total lengthlsize <br /> FILTER BED ` r`'❑ Distance to nearest: Well" _- Foundation I0 Property Line +S <br /> SEEPAGE PITS A\Daeptfi'� - S­75iie� � � �Number <br /> SUMPS" 1 ❑ Distance to nearest: Weil fF_ Foundation�5�_ _.—_ Property Line <br /> DISPOSAL PONDS [. ❑ <br /> hereby certify that I.have prepared.this applicaiion and that_the will be done in accordance with San Joaquin couniy`ordinances, state laws, anc <br /> rules and regulations of the San Joaquin Local Health district. <br /> i Home owner or licensed agent's signature certifies the following:""i <br /> employ any person in such manner as to became s``utijecS•to .certify that in the performance of the work for which this permit is issued, I shall not <br /> 'workrfman'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 fo'r which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m all fof,all r- d in c ions. Complete drawing on reverse sl <br /> Signed X Title: e • ' Date: <br /> r- FOR DEPARTMENT USE ONLY9 �'} <br /> Application Accepted by Date ! ) � - Area ! 1J <br /> or Grout Inspection by Date L_;21� Final Inspection by <br /> L� <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, Sik., CA 95291 <br /> r <br /> FEE AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> ,INFO <br /> a"EH 13-241REV.1/85) rlD;� <br /> EH 14-26 <br /> i <br />