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r <br /> APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,..STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED , <br /> (Complete in Triplicate) s. <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 Address Phone <br /> Contractor ess (cense No./ Phone L/ <br /> TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTlO <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ HER ❑ C , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS D. PROP. LINE �V <br /> FOUNDATION AGRICULTURE WELL,. - R WELL PITS/SUMPS <br /> INTENDED USE + TYPE OF WELL PROBLEM AREA CONSTR N SPECIFICATIONS <br /> C1 Industrial El Open Bottom ❑ Manteca Di Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications $ <br /> ❑ Public D Other El D Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Dep Eastern Surface Seal Installed by <br /> Repair Work Done ❑ .-Type of P H.P. f State Work Done <br /> Well Destruction ❑ Well ameter _ Sealing-Material(top 501' ` <br /> epth ° filler Material (Below 50'1 <br /> i <br /> TYPE OF SEPTIC W0,R9: NEW INSTALLATION L. REPAIR/ADDITION ❑ DESTRUCTION ❑`INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation-will serve: Rest ence— "Commercial_ Other A <br /> Number of living units: I f Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: depthR s <br /> Water table g <br /> SEPTIC TANK IDType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT- ❑' Methodof Di 4sal <br /> Distance to nearest: Well Foundation� Property Line <br /> r f r <br /> LEACHING LINE ❑ No. & Length of lines- :. -66 Total length/size <br /> FILTER BED. ❑ Distance to nearest: Well Foundation Property line <br /> SEEPAGE PITS ' Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 10 Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m _ c or 11 re 'red ins con . Complete dr ing averse side. <br /> . lik <br /> Signed X Tit Date: _q <br /> 16N <br /> FOR IDEPKRTMENT USE ONLY <br /> i Application Accepted by / Daterea <br /> P If <br /> Pit or Grout inspection b Date r Final Inspection'by Date <br /> 4 Additional Comments: N — <br /> I ❑ Stk 466-6781 OKLodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copie3to: Environmental Health:Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA.952U1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> s � <br /> + EH 13-24 IRM 1/a 5) <br /> EH 14-26 N (( <br />