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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaqui3n Local Health District for a permit to construct and/or install the work herein described. This application is <br /> APP I <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1851 for wall/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City <br /> L L � ot Size PM I <br /> Job Address <br /> /? � I Phone 0 <br /> Owner's Name /rr US f J'A Address <br /> Phone <br /> Contractor's Name License No. <br /> WELL REPLACEMENT ❑ DESTRUCTION <br /> TYPE OF WELL/PUMP: NEW WELL E7PUMPREPAIR ❑ OTHER El <br /> PUMP INSTALLATION ❑ , <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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type <br /> of Casin Specifications <br /> El Domestic/Private ❑ Gravel Pack E3 Tracy g Type of Grout <br /> 11 Public ❑ Delta Depth of Grout Seal <br /> ❑ Other 4 ; <br /> rox. De th—t]-Eastern�-"^^--Surface-Seal installed by --- —�" <br /> El Irrigation —�`pp State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction [I Well Diameter �. Sealing Material {top 50'1 1) <br /> Depth FillerMaterial {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION. (No septic system permitted if public sewerriis <br /> i i available wiihin 2W feet.) w <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms *. .Watdi-table depth <br /> Character of soil to a depth of 3 feet: <br /> No.,Compartments <br /> SEPTIC TANK Ll Type/Mfg'' — - �.Capacity <br /> �.: Method of Disposal �. <br /> PKG. TREATMENT PLT. ❑ Property Line 1 <br /> Distance to nearest: Well Foundation � <br /> Total length/size <br /> LEACHING LINE EJNo. & Length of lines pr6pe'rty Line <br /> FILTER BED 11 Distance to nearest: Well Foundation <br /> Size Number <br /> SEEPAGE PITS ❑ Depth <br /> IFoundation Property Line ' <br /> SUMPS 13Distance to nearest: Well .`t y <br /> I 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 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 per n in such manna s to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signatureensa <br /> certifies the fol ng:"I certify t at i the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa <br /> k tion laws of lif nla." <br /> The applican m call for. II wired ' pections. Complete drawing on reverse side. <br /> Title: Date: <br /> Signed Date Area � <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> Application Accepted by z-- <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> ApplicantReturn all copies to: Environmental Health Permit/Services 1601 E. Hazeltoh Ave., .P.O. Box_2009; Stk CA 95201 ti. <br /> FEE CK RECEIVED BY DATE ;1? <br /> ERMWAO. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> S -17 <br /> +EN 13-20[REV.101831 c a ^171 •! <br /> EH 1426 <br />