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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE„ STOCKTON, CA SAn <br /> Telephone (209) 466-Ml I r r4i-!-e 7 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> -- (Complete in Triplicate) V(r c �� <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 /> f Job Address a� � Ci Lot Size pM <br /> Owner's Name 'Address` Z <br /> Phone <br /> Contractor, Address License No. �--� Phone �– <br /> TYPE OF WELL/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 /> FOUNDATION AGRICULTURE WELL ' ' - OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ 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 �pprox}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 # Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION ❑ 'DESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms M <br /> Character of soil to a depth of 3 feet-1 Water table depth i <br /> SEPTIC TANK L1Type/Mfg Capacity No. Compartments ! <br /> PKG. TREATMENT PLT. ❑ -ted" _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> j <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance tb nearest: Well Foundation Property Line <br /> j <br /> SEEPAGE PITS ❑ Depth j Size Number <br /> SUMPS ❑ Distance to nearest: Well F Foundation Property Line <br /> DISPOSAL PONDS ❑ d:` , <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 mu alt for all req ired in Complete drawing on r side. <br /> Signed - Title: <br /> A? <br /> e <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments: R <br /> Cl Stk 466-6781 C1 Lodi 369 3621 ❑ �ntca 823-7104 ❑ Tracy <br /> Applicant Retum all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 i <br /> k . <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO +j CASH <br /> + EH 3-24 EH 1428iREV.S/e51J� <br />