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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> k t� 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 County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> �.�� �eLC�.,i : D.: Lot Size- /PS M <br /> Job Address ✓� City <br /> Owner's Name Address <br /> s r Phone <br /> Contractor Address License Na. � 6 SIlia—Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEM NT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION'I� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK`. _ SEWER LINES DISPOSAL FLD. PROP. LINE _76Z <br /> FOUNDATION` AGRICULTURE WELL OTHER WELL PITS/SUMPS !L <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing <br /> DomesticlPrivate p(Gravel Pack ❑ Tracy Type of Casing 4&K Specifications I'6A <br /> ❑ Public ❑ Other ¢ ❑ Delta Depth of Grout Seal Type of Grout <br /> i ` <br /> ❑ Irrigation /JA"pprox. Depth ElEastern Su ace 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 3 Lit <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 0 f <br /> available within 200 feet.l <br /> Installation will serve: Residence— Commercial_ Other <br /> �—Number-of-living units:• -- —Number-of-tied <br /> i ter.:ti w�c Water table depth <br /> t Character of soil to a depth of 3;feet: <br /> 'SEPTI TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t Distance to nearest: Well Foundation Property Line <br /> I A 1 <br /> 1 <br /> LEACHING LINE ❑- No.'& LengTotal length/size <br /> of lines 9 <br /> Xh t I <br /> FILTER BED; i 19 ❑ Distance to nearest: Well Foundation Property Line <br /> 4 .. 10 w <br /> SEEPAGE-P1 ❑ Depth Size Number <br /> ;SUMPS hl' I ❑ Distance to nearest: Well Foundation Property Line <br /> �DISPOSAL.PONDS ❑ <br /> .�.. <br /> 'I hereby.certify t>1at 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 Jbaquin"Local Health District. <br /> Nome owner or licensed agent's sihnatuie 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."Contractors hiring or sub contracting signature <br /> icertifies 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 compen - <br /> tion laws of California." I 1 <br /> :The applicant must cal r 11 re uired inspe�c ns. m lete drawing on reverse side. <br /> Signed Title: &-a Date: <br /> FOR DEPARTMENT_USE ONLY <br /> ( y w ""'""pteDate -: Area Z <br /> Applic"ation Acced by <br /> gs <br /> Pit or Grout inspection by Date V Final Inspection by Date <br /> d,Additional Comments: <br /> 466-6781 E] Lodi 369-3521 E3Manteca 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 (tc <br /> a FEE AMOUNT DUE,;; AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`N0. <br /> INFO <br /> + EH 13-24(R 1/s5) .. g... b� P ! �,�_�a^-� 4004 <br /> EH 1428 - <br />