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i <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 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 ( \I City _!` ot SizeSQ, 10 PM <br /> _PIA <br /> OiRner's Name L 1 1 Address _�� IA _ Phone <br /> t;G-- 95-eA r r+-72--O t alp <br /> Contractor Address License No. Phone_ <br /> TYPE OF ELL/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 Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications o <br /> F1 Public ❑ Other ❑ Delta Dopth of Grout Seal Type of Grout <br /> I I Irrigation _.-Approx. Depth l I Eastern Surface„Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done. <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth C Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION l I DESTRUCTIO (No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence"� Commercial ” Other` "`" `= <br /> Number of living units: Number of bedrooms w <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg . Capacity` No. Compartments t <br /> PKG. TREATMENT PLT. ❑ b �y. �.- r Method of Disposal t� <br /> Distance'to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> w. .1 <br /> SEEPAGE PITS I I Depth Size . _ Number <br />"+ SUMPS ❑ Distance to 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. <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 call for all requir$ ins ct�ions. Complete drawing on reverse side. � <br /> Signed X Title: r­,"4r Date: 61 <br /> FOR DEPARTMENT USE ONLY r <br /> Application Accepted by Date Area <br /> F Pit or Grout Inspection by Date Final Inspection by G <br /> Additional Comments: 6 <br /> I� R <br /> ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <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 A6 RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> TZtm <br /> i` ♦ EH 13-24 iREV.119 51 ��� • r 1J� Z- <br /> EH 1426 - - <br />