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3 1^ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1•YEAR"FROM DATE ISSUED <br /> r r (Complete in Triplicate) <br /> _,,, �, r , <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. „?1 <br /> Job Address �� ks� City xLot Size <br /> PM <br /> k Owner's Name Address = C-0 <br /> " Phone <br /> r <br /> Contractor Address 672a t 1� -sc-��-� License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Y� 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 Dia. of Well Casing ` <br /> X.Oomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ._.__Approx. Depth El Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump P A � H.P. State Work Done <br /> Well Destruction ❑ Well Diameter' Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> available within 200 feet.) V1 <br /> Installation will serve: Residence Commercial_ Other V <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: # Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT:❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total'length/size s <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth , Size Number <br /> SUMPS ❑ Distance t6 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. A <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."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." <br /> The applicant must c ll or all requir inspections. Complete drawing on reverse side. <br /> Signed Title: Date-5 I t, <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date-:"` I Area O <br /> Pit or Grout Inspection byDate Final Inspection by Date,7� <br /> �. <br /> Additional Comments: 4.1 <br /> ---- <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE _ AMOUNT REMITTEDCASH -. RECEIVED BY _ DATE PERMIT"ND. <br /> + EH1 -24fREV.f/951 5.` , �` /�.31i!S� �s�_5Z8 <br /> EH 1428 <br /> t <br />