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{ <br /> APPLICATION FOR PERMIT n i <br /> *} SAN JOAQUIN LOCAL HEALTH DISTRICT V P <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <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 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 /> Job Address yF b <br /> 1 {§ (� Cit Lot Size PM <br /> Owner's Name L� Y ic t Address O <br /> Phone <br /> Contractor- Address <br /> License No. Phone <br /> M TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 <br /> ($Domestic/Private EI Gravel Pack of Casing Dia. of Well Casing <br /> ❑ Tracy Type (� <br /> f 1 PublicCi Other Specifications <br /> Cl Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation —._Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. - d <br /> State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 501 ^� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is l l� <br /> Installation will serve: Resid ` AL <br /> ence Y CommercialOther vailable within 200 feet.) VVV <br /> ` <br /> Number of living units: !Number of bedrooms_4 <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth G <br /> ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT. ❑ No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation property Line <br /> LEACHING LINE ❑ No.. Length of lines <br /> Total length/size <br /> FILTER BED 171 Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS i I Depth Size <br /> ` SUMPS � Number <br /> L-1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that f 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: "I certify that in the performance of the work for which this permit is issued,I shall <br /> tion laws of California." employ persons subject to workman's compensa- <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by l <br /> Date Area <br /> Pit or Grout inspection by Date Final Area <br /> by <br /> Date 2— <br /> Additional Comments: <br /> ❑`Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I <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 7 /�1CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EHT3-24tttEV:l/H55 J '�[:�C f/} <br /> EH T4-28 <br />