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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 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 Address -�u1u�l� (��t - City Lot Size PM <br /> Owner's Name K"1 -- Address <br /> R ! Phone <br /> Contractor tTAddress ea 3p <br /> License No.403#96.Z- Phone me t f<r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WEL-L REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ML SYSTEM REPAIR A, OTHER ❑. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> omestic/Private El Gravel Pack El Tracy Type of Casing <br /> Specifications <br /> M Public Cl Other Cl Delta Depth of Grout Seal <br /> I 1 Irrigation _ A Type of Grout <br /> pprox. Depth I 1 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 50') <br /> Depth Filler Material (8elow~50'1 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I -DESTRUCTION-1 I (No septic system permitted it public sewer is N <br /> available within 200 feet.► <br /> itilnstallatian will serve: Residence_ Commercial i Other <br /> Number of-living units: Number-of--bedrooms--= <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> _ ❑ Type/Mfg Capaeity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> _No. <br /> of Disposal <br /> k Distance to nearest: Well Foundation Property Line r <br /> LEACHING LINE ❑ No. & Length of lines <br /> 1 Total length/size <br /> FILTER SED ❑ Distance to nearest: Well Foundation �- <br /> . � Property Line <br /> ,,.SEEPAGE PITS I I Depth Size <br /> Number <br /> SUMPS 0 Distance to nearest: Well —Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> I 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 <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 shaft employ persons subject to workman's compensa- <br /> tion tron Eaws of California." - <br /> The applicant must call for all recleed inspections. <br /> -Complete drawing on reverse side./ <br /> Signed X � " ' 1 � p <br /> Title: Date: i 2^G 5 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by r 2 <br /> DateArea <br /> Pit or Grout Inspection by Date Final Inspection by <br /> ze <br /> 0A Date G <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return al1 copies to: Environmantal Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 <br /> I <br /> FEE AMOUNT DUE t AMOUNT REMITTED CK <br /> INFO - CASH RECEIVED BY DATE LPERMIT'NO].EH 13-24{REV.rEH 14-26 <br />