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i <br /> APPLICATION`FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES•1 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �!�-J >/�Q �� City , g[1` Lot Size_141 L PM <br />! Owner's Name Za., / Address ��hi <br /> A(G" Phone t <br /> `f <br /> Contractor .� - t'` "License No:=-- - "r Phone_ _ <br /> Address ­­ <br /> YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL'FLD. PROP. LINE <br /> FOUNDATION i AGRICULTURE LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRO M AREA C NSTRUCTION;SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Mante ia. of Well Excavation Dia. of Well Casing <br /> ;i <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> [').Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _ A _ <br /> g• _Approx. Depth f I Easter S ce Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State WorkDone_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> �i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [] REPAIR/AD N.1-1 DESTRUCTION (No septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> ' Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms l <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: Well Foundation N Property Line t <br /> LEACHING LINE -❑;; No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation 1 Property Line <br /> SEEPAGE PITS 11 Depth Size 9 Number <br /> SUMPS D Distance to nearest: Well Foundation i, Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l 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! <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 iso issued, I.shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all require in ions. Complete drawing on reverse side <br /> igned X Title: �t>,�? P)' Date: <br /> �4 <br /> _ FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date —�� �,�/►--r ` ' <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> li <br /> Additional Comments- <br /> 0 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 /> h a <br /> INFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY FEEDATE PERMIT'NO. <br /> p t <br /> + EH 13-24(REV.1/85) <br /> -26 <br />