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>F <br />~ F Es <br /> z APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT .C� �^`�• <br /> 1601 E. HAZELTON AVE., STOCKTON, CA , <br /> Q <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE'ISSU.ED '� <br /> (Complete in Triplicate) "'C�.�">z. <br /> P P <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 /> SII <br /> � n 1 r <br /> Job Address City 5 o Lot Size PM <br /> Owner's Name , V'1! Address Phone —S <br /> C F <br /> Contractor J e Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t <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 --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P.` I ' State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> .. available within 200 feet.) <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 i. <br /> SEPTIC TANK"- � Type/Mfg r Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ti . .. Y ` J Method of Disposal <br /> Distance to nearest: Well Foundation Property Line j <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property'Line <br /> SEEPAGE PITS X Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 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 appl'! a must call fo all required inspections. Complete drawing on reverse side. �a <br /> Signed T Title: —_-- Q p W <br /> g �'(.�/1 Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by pater Area 02) <br /> Pit or Grout Inspection Date Final Inspection by Date t <br /> Additional Comments: . <br /> ❑ Stk 466-6781 L1 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 2008, Stk., CA 95201 <br /> a <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH K 0 RECEIVED 8Y DATE PEERM17'NO. <br /> * EH 13-24 1REV.1/n 51 25 �O �ru ` � <br /> EH 1428 1•�/ <br />