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449 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> y 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> T.elephorle (209) 466-6781 . S — <br /> i PERMIT EXPI{CIES 1 YEAR FROM DATE ISSUED 3 <br /> [Complete in Triplicate) <br /> t <br /> Application is hereby made to the ban Joaquin Local Wealth 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 /> ! 1 : City • O Lot Size PM <br /> Job Address <br /> Address � 1v� � O Phone <br /> Owner's Name <br /> g!0 icense No. � Phone 6"Z1� <br /> Contractor h a . dt� .4Address P <br /> a TYPE OF WELL/PUMP: WELL ❑ WELL REPLACEMENT C] DESTRUCTION LJ <br /> PUMP INSTAL_ N ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES R SAL FLD. PROP. LINE <br /> FOUNDATION ICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA DNSTR ION SPECIFICATIONS <br /> Li industrial <br /> EJ open Bottom ❑ Manteca Dia. I Excavation Dia. of Well Casing <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing — <br /> f Delta Depth of Grout Seal Type of Grout <br /> 17 <br /> t`1 Public Cl Other ;� <br /> ❑ <br /> 1Irrigation Approx: Depth 11 Eastern Surface Seal Installed by <br /> I Repair Work Done ❑ Type of Pump H.P. � <br /> State Work Done <br /> F SealingIMateYiai (to 50'1 <br /> Well Destruction ❑ Well Diameter * tr p <br /> Depth Filler Materials{Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I I DESTRUCTION INo:septic system permitted iF,public sewer is <br /> r available within 200 feet.I <br /> Installation will serve: Residence, Commercial Other �TP <br /> t 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. L1Method of Disposal <br /> I <br /> DistaAe to nearest: Well Foundation Property.Line <br /> LEACHING LINE 111No. & ength of Ales �f Total length/size l s <br /> FILTER BED' ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depthf --y�� Size Number <br /> SUMPS ❑ Distance to neai•est:'R""'""Welt Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l 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 Jdaquin Local Health Di§trict, <br /> t 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'employ persons subject to workman's compensa-. <br /> Tion laws of California.'-c { <br /> The applicant must call for all required inspections. Complete drawling-son reverse side:,�� <br /> A /r R C!o Date: "I S <br /> Signed Title: i <br /> FOR DEPARTMENT USE ONLY „ <br /> Date !� Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection by to <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi :3 -3621 ❑ -meta 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to:'En#ironmental Health Permit/Services 1601 E. Hazelton Ave., P.0- Box 2009, Stk., CA 95201 <br /> f F <br /> FEE AMOUNT DUE AMOUNT REMITTED] CK 9 CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> r.EH 1324(REV.r H 5) L (.� /"' ��•� <br /> EH 14-26 <br />