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x <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATEISSUED <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 t <br /> D c <br /> City !.. .. Lot Size <br /> }i _ PM <br /> Owner's Name <br /> Address <br /> - _ Phone <br /> Contractor Address e`+ <br /> TYPE OF WELL/PUMP: License No. _Phone `t9 <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca - Dia. of Well Excavationf <br /> El -0❑ Gravel Pack Dia. of Well Casing <br /> t ❑ Tracy Type of Casing <br /> ❑ Public ❑ Other ❑ DeltaSpecifications <br /> Depth of Grout Seal <br /> 1-1Irrigationof Grout <br /> Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H p f <br /> Well Destruction El Well Diameter State Work pone <br /> Sealing Material (top 50') s <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTI"vailable <br /> o septic system permitted if public sewer is <br /> within 200 feet.) ' <br /> Installation will serve: Re idents� Commercial— Other - <br /> Number of living units: T Number of bedrooms <br /> Character of sail to a de th of 3 feet: l' I <br /> SEPTIC TANK ! Type/ No. Comport ants <br /> Mfg `4P1-I' ^ ^"---*- Water table depth <br /> PKG. TREATMENT PLT. ElI <br /> "'"� Capacity m <br /> Method of Disposal f <br /> + Distance to nearest: Well Foundation 'Props Line <br /> 1 ;� t� E <br /> LEACHING LINE ` 1 { <br /> ❑ No. & Length of lines � Total length/size � <br /> FiLTER BED # ❑ Distance to nearest: Well <br /> Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS Number <br /> ❑ Distance to'nearest: Well Foundation DISPOSAL PONDS ❑ r Property Line <br /> ti <br /> 1 hereby certify that I have prepared this application and that the work wiil.be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. f <br /> Home owner or licensed agent's signature certifies the following: "!ce f <br /> employan rtify'that in the performance of the work for which this permit is issued, I shall not <br /> y 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 employ persons subject to workman's compensa- <br /> tion laws of California." ,�,.,,_ <br /> The appfrca ust cal a squired inspections. Completedra+wi g on-reverse side. <br /> Signed I I <br /> Title: Date: <br /> F 111,1DEPARTMENT USE ONLY <br /> Application Accepte y Date ga Area <br /> Pit or Grout Ins � �1 <br /> _I� _ <br /> byw -Date - Final Inspection by Date A— <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 <br /> Applicant- Return ail.copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> =,RECEIVED BY DATE I PERMIT`;NO. <br /> dJ l <br /> + EF11r�-241REV.t/esl •" «✓ � i <br /> EH 1426 � C��'Y�� <br />