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1 <br /> ' APPLICATION FOR PERMIT yy <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 4'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 Coun rdinance o. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 4Q� /�p ,4IX <br /> 4 v City / Lot Size u PM <br /> r4 Job Address <br /> 4 Phone <br /> Owner's Name Address <br /> �Contractor /f► ! Address 2 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 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> C <br /> INTENDED USE TYPE OF WELL _PRO_E LEM AREA CONS_TRUCTIO_N-SPECIFICATIONS *1 <br /> ❑ Industrial ❑ Open Bottom L1 Manteca Dia. of Well Excavation <br /> Dia. of Well Casing U" <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ., Type of Casing Specifications <br /> AOI <br /> 1-1 Public n Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth r I 1 Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction LlWell Diameter Sealing Materialftop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is [1 <br /> Commercial <br /> within 200 feet.) \r/ <br /> Installation will serve: Residence= Commercial—Other <br /> Number of living units: Number of bedrooms Z` <br /> —Character-of-soit to-a depth of 3 feet: 011,1 Water table depth <br /> SEPTIC TANK . Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. Elt . Method of Dis os�l <br /> r <br /> Distance to nearest: Well 0 Foundation '' v J� Property Line," <br /> lit <br /> F j LEACHING LINE 9L No. & Length of lines Total length/size <br /> - ef? <br /> FILTER BED ❑ Distance to nearest: Well. Foundation o Property Line, <br /> SEEPAGE PITS n T �l I Depth 5ize _ Number <br /> SUMPS -r~,._., ❑ t Distance to nearest: <br /> well 1 Foundation' Property Line <br /> DISPOSAL PONDS ❑ r <br /> state laws and <br /> count ordinances, , <br /> I have prepared this application and that the work will be done in accordance with San Joaquiny , <br /> I hereby certify that p p P <br /> f 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 /> t to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to become subjec <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 /> y <br /> tion laws of California." <br />{ Theapplicant must call for al req 'ed inspections. Complete drawing on eveise side. <br /> Signed X Title: rJf-- Date: <br /> VIA <br /> FOR DEPARTMENT USE ONLY <br /> Date "7a'0 Area / <br /> Application Accepted by + <br /> Pdor Grout Inspection by, — — Date- Final Inspection by w Date 4 <br /> Additional Comments: <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT NO, <br /> INFO CASH Q <br /> -0 b� b Z r <br /> . ♦ EH 13-24 1REV.I/n 5) �'�� <br /> EH 1426 <br />