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' 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 /> 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 t City Lot Size PM <br /> Owner's Name Address Phone <br /> Contra ctoll ���ddresS 1lnse No. fir- Phon _ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ r SYSTEM REPAIR FK- OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> C 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 /> 1"1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth l I Eastern f Surface Seal Installed by <br /> Repair Work Done Type of Pump _... H.P. ��� _ State Work Done SP <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') _ (� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 204 feat.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <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 DiI <br /> Distance to nearest: Well Foundation Property Line_ <br /> LEACHING LINE a ❑ No. & Length of lines Total length/size AUG O 1989 <br /> FILTER BED "' ❑"'Distance to'nearest: Well ___.._.._. Foundation Property Line <br /> TIJ <br /> SEEPAGE PITS I I Depth Size Number EN�RE)I 7lCCI <br /> SUMPS , L� Distance to nearest: Well Foundation Property Line ERVICE. <br /> 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 Di$trict. <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 /> to <br /> tion laws of California." <br /> The applicant I for all requilled ' mplete drawing on reverse side. <br /> Signed X Title:, � <br /> � - Date:D <br /> F R QEPARTMENT USE ONLY <br /> Application Accepted by Data Area 90; <br /> Pit or Grout Inspection by DataFinal Inspection by Date 2 <br /> i <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 <br /> CK 0 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 1328(REV.t/K 51 35 I / <br /> EH 14-28 l� "� 7' <br />