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k <br /> k <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 52091 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 j4aquin Counjty Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. f/ <br /> f ' 7;4eP <br /> i Job Address �-��� City iza o� p4- <br /> Owner's Name ddress a[ hone � <br /> Contractor's Name r censee_N No. 2ti '��� Phone1 <br /> TYPE OF WELL/PUMP: NEW WELL L WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t PUMP INSTALLATION 9�_— F SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD:� PROP. LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,,�/ <br /> El Industrial &'�n`Bottom C1 Manteca Dia. of Well Excavation.- Dia. of Well Casing y <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �� <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal f Ty �`o. Grout <br /> ❑ Irrigation --Approx. Depth ❑ sterndace Seal Installed by 4 "� <br /> + Repair Work Done ❑ Type of Pump , H.P. gff State Work Done ' <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 k <br /> Depth Filler Material (Below,50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/.ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if.'public sewer is <br /> available within 200 feet.l �Cr <br /> " Installation will serve: Residence— Commercial.____ Other l; <br /> Number of living units: Number of bedrooms Z1 , rt11 <br /> Character of soil to a depth of 3 feet: Wateratable.depth <br /> SEPTIC TANK ElType/Mfg Capacity No. Compar mints �• <br /> PKG. TREATMENT PLT. ❑ 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 /> k SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS " ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 ' <br /> 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 /> t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which#lis permit is issued!l shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors`hiring or sub-c6­;tra6ng 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." f` <br /> k The applicant miLst call for all required 1rispections. Co p to drawing on reverse side. + <br /> l Signed Title: r Date <br /> FO�DEPAR�TMENT USE ONLY <br /> Application Accepted by lie Date ?,Area d <br /> Pit or Grout Inspection by Date Final Inspection by1P <br /> s Date <br /> Additions! Comments: - <br /> }r Y �❑ Stk 466-6781 ❑ Lodi 369,3621 O Ma`riteca X673=7104""` 17 Tracy 835-6385 <br /> ? Applicant=Return all copies to:Environmental-Health-Permk Services 1601-E:Hazelton-Ave.,-.P.O._Elox 2009, StV to 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY ! DATE' rPERMW'N0. <br /> EH 14-28 <br /> +EH t3-241REV.101834 `4y �► + _L� <br />