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�1 <br /> �. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 No �J v."►—� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> do <br /> (Complete in Triplicate) R <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein stride bs 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 Addressp] � � (J /`T/J 6 City of Size PM <br /> ' I <br /> Owner's Name e bat�e? Address 02lo �Ua!� Phone <br /> ContractorP Address License No. Phone_ <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 11 <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 <br /> n Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation -Approx. Depth I 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 Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION>Q,(No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other r <br /> 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. ❑ Method of Disposal <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 /> SEEPAGE PITS E I Depth Size Number i <br /> SUMPS D Distance to nearest: Well Foundation Property Line G <br /> DISPOSAL PONDS ❑ <br /> 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 G <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 must call for all required inspections. Complete drawing on reverse side. II <br /> Signed Title: Date: <br /> R D RTMENT USE ONLY <br /> Application Accepted by Dateea <br /> Pit or Grout Inspection by Date Final Inspection b Date l <br /> Additional Comments: r I <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'No. <br /> INFO A H <br /> +. <br /> EH 13-24(REV. i n 51i V U S ��'l U •� �5( <br /> EH 14-26 a <br />