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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQ.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) �T <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 /> C /� �) <br /> Job Address �� f Q ? Q�AA)C"" " City V Lot Size PM <br /> Owner's Name NR, 1--/, IV Address , `C.� F Phone <br /> contractor's P, --. ` "0'yLicense No. O Phone �ctor's Nam <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �- <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> b 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 /> r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavafion'# Dia. of Well Casing <br /> Ll Domestic/Private L3 Gravel Pack E3 Tracy <br /> Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout . <br /> ❑ Irrigation ---Approz Depth ❑ 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 1 Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11REPAIR/ADDITION DESTRUCTION El (No septic system permitted if public sewer is__.;r <br /> 5 I available within 200 feet.) <br /> i <br /> Installation will serve: Residence Commercial_ Other y <br /> Number of living units: Number of be rooms <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK Type/ g u Capacity D No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> s <br /> # <br /> Total length/ <br /> LEACHING LINE No. & Length of lines g <br /> l <br /> 'FILTER BED El Distance Distance to nearest: WeltFoundation Property Line <br /> f <br /> SEEPAGE PITS �Depth l3 �� SizexZ1 Dumber <br /> tt SUMPS Distance to nearest: Well /00 Foundation�Q'� Property Line _ <br /> r=l' DISPOSAL PONDS ❑ Utah/Of)—�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, 1 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." <br /> The applicant mu all r uired ins ns. plate drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> -JVD <br /> 1 Application Accepted by Date -4if Area <br /> Pit or Grout Inspection by i Date Final Inspection by <br /> Additional Comments: I <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 823-7104 ❑Tracy 835-6385 / <br /> Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> LA <br /> F <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'ND. <br /> INFO <br /> + EH 13.241REV.10/831 <br /> EH 14-26 <br />