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4. <br /> F 'mow. <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 /> f <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. 18652 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> f C <br /> Job Address r / City� 01ot Size PM <br /> Address ! In Phone <br />� Owner's Name .- - <br /> Contractor's Name icense No. '� on�T <br /> TYPE OF W LL/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 />' -....�_ .-.n_..�sa .... .. ._. <br /> _ ---- FOUNDATION �--=AGRICULTURE WE4L­ - -- OTHER-WELL'- --�ITSd•SUMPS -- • <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> k ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well.Casing <br /> ❑ 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 Surface Seal Installed by l <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> I Well Destruction ElWell Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 9L_ZW8T9UCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) t <br /> Installation will serve: Residence✓ommercial— Other <br /> Number.of living units:__L Number of beootfm'�' - <br /> { <br /> Character of soil to a depth of 3 feet: �1)� T C Water table depth S <br /> i SEPTIC TANKR )hype/Mfg C) r�1 CV'f.':` I` Capacity No: Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> " t•�; Distance to nearest: Well Foundation Property Line S <br /> LEACHING`LINE 9-14c. & Length of lines "f ."Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line f <br /> n <br /> SEEPAGE PITS S-­6epth Size - T f - Number <br /> SUMPS ❑ Distance to nearest:, Well Foundation Property Line i <br /> DISPOSAL PONDS ❑ Y <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 District. <br /> i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permityis issued, i shall not <br /> f 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 ffie following: "I certify that in tfie performance of the work for which this permit is issued,I shall.employ persons subject to workman's compensa <br /> laws-of Cal'rfor ' - I <br /> I <br /> e app t mu .cal for II re it pec�ns. mplete drawing on'reverse side i <br /> Signe <br /> Title: Date: <br /> S FOR DEP ..RTMENT USE ONLY l <br /> Application Accepted by / r <br /> Date Area <br /> CJ y�` DateC�S� <br /> Pit or Grout Inspection by - Date Final Inspection b Y <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 /> i IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> ♦ EH 13-24 IREV.10/831 ; �—� <br /> 373 0 <br /> EH 1428 <br />