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APPLICATION FOR PERMIT <br /> e <br /> SAN JOAO,UIN LOCAL HEALTH DISTRICT 4 � <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 N 0 Lo � <br /> PERMIT EXPIRES 1 YEAR FROM DATE'.ISSUED <br /> (Complete in Triplicate) n <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. r <br /> Job Address �}13� �,sx►-,n` a- City . Lot Size PM <br /> Owner's Name - n., .:-.�^' Address 1, Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: Nk 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 /> F INTENDED USE' """"`TYPE OF-WELL PROBLEMAIiEA CONSTRUCTIC+N 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 /> C Irrigation ---Approx. Depth ' ❑ Eastern Surface Seal Installed by j <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction El—Well Diameter Sealing Material (top 501 <br /> l}� <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION XTNo septic system permitted if public sewer is <br /> i -available within 200 feet.) <br /> Installation will server Residence_ Commercial_ Other <br /> Number of living units; — Number of bedrooms' r rte. <br /> Character of soil to a depth of 3 feet: ) Water table depth <br /> SEPTIC TANK t ❑ Type/Mfg Capacity No. Compartments 5� <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line, <br /> t k <br /> LEACHING LINE. ❑ No. & Length of lines ' Total length/size <br /> FILTER BED ❑ Distance to nearest: - Well Foundation. Property Line <br /> SEEPAGE PITS ❑ Depth Size Number i <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t <br /> 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_Jcgquin-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 required inspections. Complete drawing on reverse side. j <br /> t <br /> Signed .. Title: Date: —/7— <br /> FOR DEPARTMENT USE ONLY <br /> ApplicatonAupbt yn "Q� <br /> (� <br /> Pit or Grout Inspection by Date� Final Inspection by yu Date <br /> Additional'Comments: <br /> Az <br /> ❑ Stk 46616781` ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354065 <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 CCK 4 RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-24(REV.1/e5) - " [��� <br /> EH 14-28 v\ 3r(7/ �.-- <br />