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iIt <br /> �f APPLICATION FOR PERMIT <br /> it <br /> i1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> u � <br /> it 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> J1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) i <br /> i <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. }, 1� <br /> Job Address . 1"L 7� City Lot Size PM <br /> Owner's Name Address Phone <br /> Contractor II Address License Nz-gcl kb Phone <br /> ZZ <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 f* Dia.'of Well Excavation . Dia:of Well.Casing, : <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f"1 Public ❑ Other CI Delta Depth of Grout Seal T <br /> ype of Grout ,� I <br /> I°I irrigation --A-Approx. Depth I i 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 50'1 <br /> Depth Filler Material (Below 501 <br /> nr <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ] DESTRUCTIO X iNo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> r <br /> " Installation will serve: Residence Commercial_ Other <br /> 5-Number of living units: ,I Number of bedrooms \J1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> h <br /> SEPTIC TANK Q Type/Mfg Capacity - - No. Compartments <br /> PKC. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Totaf length/size <br /> FILTER BED ❑ . Distance to nearest: Well 'Foundation Property Line <br /> p <br /> SEEPAGE PITS 1-1 Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property fine <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 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 i s an r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followi g: " if at 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 Calif nia ' Ir <br /> The applicant m I all uired inspections. Complete drawing on reverse side. <br /> Signed X i Title: _ Date: <br /> I� FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area l <br /> Pit or Grout Inspecti n I�. Date Final Inspection by Date <br /> Additional Comments: I� <br /> I-) Stk 466-6781 ❑ Lodi1 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return ail copies to:ff Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95201 <br /> • .II <br /> INFO AMOUNT DUE AMOUNT REMITTED CCK 4 RECEIVED BY DATE PERMIT'NO. <br /> t EH13.24 IREV.i <br /> EH t4-26 0 <br /> it <br />