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`4 a <br /> 'I <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 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 /> i <br /> Job Address J d z • City/%,'r"_ Lot Size _" PM j <br /> Owners Name Address <br /> 3 1-3 I <br /> Contractor Address License No. Phone i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i. <br /> Y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL) PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack-- `❑ Tracy `� Type of Casing Specifications i <br /> * Public" Ll Other ❑ Delta Depth of Grout Seal Type of GrouE <br /> I 1 Irrigation _.Approx. Depth I 1 Eastern Surf ce Seal Installed by - <br /> Repair Work Done Fl Type of Pump -'H:P:--t - State Work Done T <br /> Well Destruction El Well Diameter Sealing Material [top 501 1 f <br /> Depth Filler Material I low 50- <br /> TYPE-OF <br /> o-TYPEOF SEPTIC WORK: NEW INSTALLATION I] RCPAIR/ADDITION I DESTRUCTION ( I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> t <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms �,ry <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. ❑ d Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total Iengthlsize <br /> FILTER BED O Distance to nearest: Well Foundation Property Line P2 ._ <br /> 1i <br /> SEEPAGE PITS t I 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 accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Diltrict. <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." 4 ' <br /> The applicant must caH r all require 'nspections. Complate drawing on reverse side. (� <br /> Signed X <br /> Title: Date: <br /> OR 1'ARTkMENT USE ONLY <br /> Application Accepted by __. - Date Area / <br /> i Pit or Grout Inspection by Date Final Inspection by' Date <br /> U` <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385S� <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 <br /> of <br /> FEE AMOUNT DUE AMOUNT REMITTED C H RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH 13-24 JAEV.i/1;51. <br /> EH 14.26 ^ <br />