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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,.STOCKTON, CA <br />' Telephone 12091 466-6781 <br /> i PERMIT EXPIRES 1 .YEAR FROM DATE ISSUED <br /> a 1Complete 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 /> ' 41 <br /> Job Address k City Lot Size - PM <br /> Owner's Name 0— Address -. Phone <br /> ContractCr }Address �sO, License IVo. 0� � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ ;SYSTEM REPAIR ❑ 3. OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- —L` -'DISPOSAL FLD. PROP. LINE t <br /> FOUNDATION AGRICULTURE,WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE'OF 1NELL PROBLEM AREA'`CONSTRUCTION SPECIFICATIONS <br /> L1Industrial! 171 Open Bottom - f❑ Manteca , Dia. of Well Excavation Dia. of Well Casing <br /> ' y i <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 <br />' Repair Work:Done ❑ Type of Pump H.P. State Work Done � <br /> Well Destruction ❑ Well Diameter `" Sealing Material (top 501 <br /> Depth ler Material (Belo'w 501 9 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1REPAI ./ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> �" available within 200 feet.) <br /> Installation will serve: Residence 'Commercial_ Other <br /> , <br /> Number of living units: r or Numbef Brooms / <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. ❑ Method of Disposal <br /> Distance to-nearest:-- Weill Foundation Property Line j <br /> LEACHING LINE �o. & Length of lines' S Total length/size X> <br /> FILTER BED - ❑'Distance Yo nearest: Well_... v__. Foundation 40 f Property Line <br /> SEEPAGE PITS ❑ Depth Size Number + <br /> SUMPS. ❑ Distance to nearest: Well Foundation Property Line <br /> t 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 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 must call for all require inspections. Complete drawing on rev side. <br /> 1 �< <br /> Signed Title: 1P � Date: <br /> 1 FO DEPARTMENT USE ONLY <br /> Application Accepted by Date /Z' `Z 2 _-06(47�r Area <br /> Pit or Grout Inspection by Date Final Inspection by oDate �� u a <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT`NO. <br /> y r <br /> + EH 13-24(REV.i/e51 ! O �Q /[�C� IA— <br /> EH <br /> il--y J <br /> EH 14 � <br /> 28 �` 1 ��Ir� ) <br />