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tl _ <br /> APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - 1 <br />' 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r i <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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> s �� �. s+k_o <br /> Job Address — 17 ,r City Lot Size PM <br /> �-rl FF i�l ° <br /> Owner's Name Address <br /> - Phone i <br /> Contractor Addres License_iVo. c• Phone_ 1 <br /> TYPE OF WELL/PUMP: - NEW WELL ❑ WELL REPLACEM NT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> i PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECI,F_ICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing '. <br /> ❑ Domestic/Private ❑ Gravel Packr ❑ Tracy Type of Casing Specifications <br /> FI Public f] Other I C 1 Delta Depth of Grout Seal Type of Grout _r <br /> 1 1 Irrigation —.-Approx,,Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State WorkF Done <br /> LJ Well Destruction Wel! Diameter Sealing Material (top 501 <br /> vDepth .1 ' Filler Material (Below 50') <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION 11 : REPAIR)ADDITION I-I' DESTRUCTION l o septic system permitted if public sewer is <br /> \VT € available within 200 feet-1 r i <br /> t v <br /> t� Installation will serve: Residence_ Commercial Other <br /> Number of living units: _/__ Number of bedroortis� <br /> Character of soil to a depth of 3 feet: 1 g Water table depth a <br /> SEPTIC TANK ❑ Type/Mfg I I _ Capacity j No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: 'Well Foundation Property Line <br /> 1 LEACHING LINE ❑ No. & Length of lines rry Total length/size <br /> FILTER BED ❑ Distance to!nearest: r Well Foundation Property Line <br /> SEEPAGE PITS I i Depth I 'Size ! <br /> Number I <br /> MSUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ T w r` <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. <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 /> ertifies the followin : "I certify that in the performance;of the, ork for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion of Califor is. # i <br /> The i's <br /> st II for It <br /> r wired specti s. ompl a drawl g oSign. n r rse sid <br /> Signs A/\ <br /> Date: <br /> 0'FORDEPARTMENT USE ONLY <br /> Application Accepted by Date r �' Area <br /> Pit or Grout Inspectio Date Final Inspection by Date <br /> r Additional Comments: y ~~ I <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7f04- ❑ 7Tacy 835-6385' f <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 'I <br /> INFO FEE <br /> AMOUNTDUE AMOUNT REMITTED CK Al CASH RECEIVED 13Y DATE PERMI7'NO, <br /> r.EH 13-21(REV.t/H 51 (� ( <br /> EH 11-28 vvv ,j i <br />