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, <br /> a <br /> 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 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 compliance with San Joaquin Cou <br /> Local Health Districnty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Application <br /> �> <br /> t. r ' EF x <br /> 11 <br /> PM <br /> -Job Address <br /> s0 Q City. Lot Size <br /> Ovvner's Name �® I <br /> Address � y� `-�® `�� ' Phone r <br /> 1... # Phone <br /> Contractor <br /> �,�'L Address License No. <br /> DESTRUCTION FITYPE OF WELL/PUMP- NEW WELL E3WELL flEPLACEMENT ID <br /> PUMP INST q ELATION ❑ SYSTEM REPAIR CIOTHER El <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK /SUMPS <br /> o FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED•USETYPE OF.WELL PROBLEM AREA CONSTRUCTI ICATIONS Dia. of Well Casing <br /> Q Industrial' ❑ Open Bottom ElManteca ell Excavation <br /> T e of Casin Specifications <br /> 0 Domestic/Private El Gravel Pack ❑ T yp g Type of Grout <br /> ❑ Public D Other L] Delta Depth of Grout Seal <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by <br /> H p State Work Done <br /> Repair Wark D Jype of Pump <br /> struction 0°'R,,_Well Diameter Sealing Material [top 50'1 <br /> Depth ' Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION F1 RE ❑` DESTRUCTION availableFwi h ne200 feetitted if public sewer is t <br /> I E' Commercial_ Other `J I <br /> Installation swill serve: Residence� r 9 <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil'..to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> t E Method of Disposal <br /> PKG. TREATMENT PLT- © " <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line + <br /> r'3 " � Well Foundation <br /> Cn� FILTER BED ❑ pistance to nearest: <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> Nu <br /> t <br /> Property Line <br /> SUMPS <br /> ❑ Distance to nearest: well Foundation <br /> DISPOSAL PONDS ❑ HI <br /> Thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, <br /> I 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." 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 /> p nt must call for all required ins ctions. Complete drawing on reverse side. <br /> s.�'V J1�� <br /> Title: <br /> Signed X <br /> r <br /> FOR DEPARTMENT USE ONLY r <br /> I Date vv Area <br /> Application Accepted by <br /> rFinal Inspectio by Date <br /> Pit or Grout inspection by Date <br /> k + <br /> ' Additional Comments: <br /> ❑ Sti 46Comi Lodi 369-3621 0 Mantec 823-7104 . ❑ Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/services 1.601 E. Hazelton Ave P.O?Box 2009, Stk., CA 9ns201. R <br /> PEE AMOUNT DUE AMOUNT REMITTED C SH r IRECEIVED BY DATE PERMIT NO. <br /> INFO .Q I <br /> '+ EW 13-24(REV.1/B5) 56 <br /> EH 14-26 <br />