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r { <br /> r APPLICATION FOR PERMIT - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L � 4 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6789 <br /> ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fl <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 r City Lot Size PM <br /> Owner's Name _ Address Phone <br /> Contractor K Address D r License No. —Phone m 2e/ <br /> TYPE OF-WELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION K SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION+ AGRICULTURE WELL OTHER WELL PITS/SUMPS __ T <br /> - INTENDED USE TYPE OF WELL . PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> L,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern S ace Seal Installed by <br /> Repair Work bone ❑ Type of Pump_ H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material /top 50'1 <br /> Depth h Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) 1 <br /> Installation will serve: Residence Commercial_ Other.— <br /> Number <br /> ther.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 t�. Capacity. No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to;!nearest: FWII <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines f Total length/size <br /> FILTER BED 171, Distance to nearest: I Well ,Foundation Property Line <br /> SEEPAGE PITS ❑k Depth Size Number <br /> SUMPS ❑, Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ! <br /> I hereby certify that I have prepared this application and that the work will be done in accordanbe with San Joaquin county ordinances, state la <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 nor", <br /> employ any person in such manner as to become subject to workman's:compensation laws of California."Contractors hiring or sub-contracting signature i <br /> certifies the following:"I certify that in the performance of the work far which-this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." I <br /> The applicatIlt t call for d inspections. Complete drawing on reverse side. 7 <br /> Signed X Title: Dater -S- <br /> 014 DEPARTMENT USE ONLY <br /> Application Accepted by Date e qr <br /> Pit or Grout Inspection by Date Final Inspection by A!YDate �S <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 <br /> INFO AMOUNT DUE l AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. , <br /> +EH13-24(REV.tits 5) / 1,7-P7 <br /> EH 14-26 6 �77 <br />