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APPLICATION FOR PERMIT 4 <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> z 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 Couitty Ordinance No;549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. w <br /> _ ``�� a <br /> City Lot Size S-.O X+j 3 C J PM <br /> Job Address }� r- ti <br /> i - . <br /> q Ph <br /> ddress �" one <br /> Owner's Name <br /> Address License No. Phone_ <br /> Contractor <br /> TYPE OF W LL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTE REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.- PROP. LINE y <br /> FOUNDATION AGRICULTU WELL OTHER WELL-PITS/SUMPS <br /> 1 <br /> INTENDED USE TYPE OF WELL PROB MARE CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Mani a Dia. of Well Excavation <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> ❑ Public ❑ Other ❑ De w Depth of Grout Seal <br /> s r ,t <br /> ❑ irrigation — pprox. Depth astern urface Seal Installed by1 <br /> Repair Work Done ❑ Type of Pump --H.P. <br /> State Work Done <br /> WelDestruction ❑ Well Diameter Sealing Materia top 501 <br /> Depth s Filler Material (Bel 50') y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION_❑ REPAIR/ADDITION ❑ DESTRUCTION aNailabpelwthm 200 feet.) if public sewer is (� n <br /> } <br /> Installation will serve: Residence; Commercial_ Other . <br /> Number of living units: Number of bedrooms (� <br /> Character of soil to a depth of 3 feet:, <br /> Water table depth <br /> SEPTIC TANK/ ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl i Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No.-& Length of'lines " Total length/size: <br /> FILTER BED ❑ Distancetonearest:- Well E Foundation Property Line ' <br /> SEEPAGE PITS ❑ Depth i Size <br /> Number <br /> SUMPS El 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 /> i Home owner or licensed agent's signature certifies tfie 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 /> : "I certify that in.the performance of the work for which this permit is issued, I shall employ persons subje <br /> o certifies the fallowing <br /> ct to workman's compensa <br /> tion laws of California." <br /> !; The applicant must call for all required inspections. Co pate drawing on reverse side. <br /> X Signed X <br /> Title: Date: <br /> 1 FOR DEPARTMENT USE ONLY <br /> Date Lf <br /> Area <br /> Application Accepted by <br /> Final Inspection by Date <br /> Pit or Grout Inspection by 1 Date r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 171 Tracy, 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520.1 <br /> I' IFEE NFO AMOUNT DUE AMOUNT REMITTED <br /> K RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV:1 6 5) <br /> F EH 14-26 <br />