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`� `' APPLICATION FOR PERMIT - <br /> #' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES IL 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job AddressIr Cit Lot Size <br /> 4 _ <br /> Owner's Name _ Li Address m - Phone <br /> Contractor � n +� ; Address � t✓ r ;k.icense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL- ❑ 1 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, PR08LEM AREA CONSTRUCTION SPECIFICATIONS , <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy t Type of Casing t Specifications <br /> (-I Public n Other ❑ Delta I Depth of Grout Seal t ° Type of Grout <br /> --- <br /> I I Irrigation —€Approx. Depth I i Eastern j Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P 4 State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i AINIADDITION [ I DESTRUCTION l I Wo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: R idence= Commercial Other <br /> Number of living units: Number of bedrooms f <br /> t F <br /> Character of soil to a depth,of 3 feet: 09 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 0A1CXe,, Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ( :j Method of Di osal <br /> Distance to nearest: Well0� `�oundation Property Line__..` _— <br /> R l <br /> LEACHING LINE L4--1qo'_:& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well_f" 0 Foundation , __ Property Line <br /> r A ot <br /> SEEPAGE PITS I-r Depth ��-�_—Size _ Number_. 5 <br /> SUMPS ❑ Distance to nearest: Well.7 Foundation .____ F Property Line <br /> DISPOSAL PONDS ❑ y y'' 1/= <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 Di§trict:- <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 /> emplorson ins h manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies thy pee lowing: 'I c fy 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 Ca rni <br /> The applicant ust all all re wired 'nspect s Co ete g on rev ase side., <br /> Signa ` Date: <br /> f 4 POR DEPARTMENT USE ONLY <br /> f <br /> Application Accepted by Date —2 �� Area <br /> Pit or Grout Inspection by Date ��/ Final Inspection by Date <br /> Additional Comments: <br /> r <br /> ❑ Sik 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:0. Box 2009, Stk., CA 95201 <br /> _FEE—— AMOUNT DUE"` -AMOUNT REMITTEDCAS RECEIVED BY"` DATE PERMIT`N6­ <br /> INFO <br /> +.EH 13-241REV.5�H 5f /�_ �.,�/ -a8 <br /> EH 14-26 <br />