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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON 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 City Lot Size PM <br /> Owner's Name A&, LAddress ����GrJ� a�<.)22P_&/ Phone 2 O <br /> i j <br /> Contractork¢ 6 Address 9, A- License No.1/ Phone 1 t4 <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 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well.Casing <br /> k1 Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications <br /> FI Public r Qther ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation -Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done IV Type of Pump H.P. St to Work Done / K�+I <br /> Well Destruction ❑ Wel! Diameter Sealing Materia! (top 50'1 - <br /> Depth Filler Material (Below 501 UU <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I } DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> 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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of.Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well FoundationProperty CiiSe­ -� ^ - <br /> DISPOSAL PONDS ❑ <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 Dilarict. <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 /> The applicant m�stQca11 for all required inspections. Complete drawing on reverse side. <br /> Signed XJ• 7 i sL-i^+ Title: Date: <br /> , FOR DEPARTMENT USE ONLY <br /> 1i& <br /> Application Accepted by � Date Area <br /> Pit or Grout Inspection b Date Final Inspection by Date;� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 <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 RECEIVED BY DATE PERMIT'NO. <br /> INFO txsn <br /> + EH 13-24 IAEV.1/4 sl <br /> EH 14-26 -��� ��� �/ L—� Q p �S <br />