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APPLICATION FOR PERMIT + <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 h <br /> made in compliance with.San Joaquin County Ordinance No.549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> PIM <br /> Address <br /> City Lot Size <br /> Jab Address l <br /> OAddress <br /> Phone <br /> Owner's Name a <br /> Address icense No <br /> Phone <br /> Contractor � �y � L <br /> TYPE OF WELL/PUMP: NEW WELL LJ REPLACEMENT El DESTRUCTION ❑ ' <br /> PUMP INSTALLATION C31 ' SYSTEM REPAIR 13OTHER ❑ a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA, CONSTRUCTION SPECIFICATIONS <br /> -❑.Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation i, Dia. of..Weil Casing <br /> ❑ Domestic/Private jDGravel Pack El Tracy Type of Casing I Specifications i <br /> G i TYpe`,of Grout - <br /> E l Public G' Other CI Delta Depth-of Grout Seal <br /> 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 /> I, Depth Filler Material (Below 50.1 <br /> TYPE OF T( ave SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I-I DESTRUCTION f I septic system permitted if public sewer is <br /> available within 200 feet.) <br /> �� Y <br /> lnstallation will serve: Residence!" Commercial Other <br /> Number of living units: __L_ Number of bedrooms ..— 3AB <br /> Character of soil to a depth of 3 feet: i l Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> AV— <br /> W Method of Disposal � <br /> PKG. TREATMENT PLT. ❑ % <br /> Distance to nearest: Well " Foundation i Property Line���Y i <br /> LEACHING LINE <br /> No. & Length of lines ' Total length/•size r <br /> 1. I PropbrwLine <br /> FILTER BED -Distance to nearest: Well Foundation" <br /> e6z. Size— -. Number4 <br /> r SEEPAGE PITS Depth r <br /> SUMPS ❑ Distance to.nearest:-­_Well' Foundation�a Y f` Property{L-ine�=�� - <br /> t DISPOSAL,PONDS; ❑ r r i t s <br /> I hereby certifya4 at I have prepared this application and that the work will be done in accordance with San.Ioaquin couniy.,or:dinancres, state laws, and <br /> i rules and regula ions of the San Joaquin Local l4e6lth oistYict. ; I ( E <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; California." Consuch marcher as to become subject to workman's compensation laws of raetor s hiring-orssub contracting signature <br /> certifies thJ 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 CaliforAU0. fx "' <br /> iI r <br /> The applicant must call for all quired inspections. Complete drawing bn reverse side. <br /> ( . ' ' Title; <br /> nod X r' Data: Sir <br /> Sigr <br /> it F,OR DEPARTMENT USE ONLY <br /> r ' <br /> Area I <br /> Application.Accepted by�T Date <br /> Pit or Grout'1�lspection by <br /> Qate -Final Inspection by o Date '2i <br /> Additional Comments: <br /> ❑-Stk 46667$1 'Ea Lodi 369=3621 ❑.Manie'ca 823-71,04 0-,Tracy. 835-6385 <br /> it <br /> Applicant- Return all c pies to: Environmental Health Permit/Services 1601 E: Hazelton Ave�P':0. Sox 2009, Stk., CA 95201 <br /> �I.CK ' <br /> "^ ' <br /> -FEE "'s`KMOd()NT DUE— AMZS�NO K NIIT rER '�fiECEIVED BY`� DATE' PERMI7 NO> - <br /> ...,,.�. -INFO. -. _ - - -. - - <br /> 1'.CASH <br /> ' 00 <br /> 14t.+.EH 13-24(REV.,ins) - 709 C h. I— K <br /> EH 14-26 <br />