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4 <br /> APPLICATION,.FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r ' <br /> 1601 E. HAZELTON AVE.,-STOCKTON, CA <br /> Telephone (209) '466-6781 <br /> PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED : ,- <br /> (Complete <br /> SSUED <br /> (Complete in Triplicate) 4;��.... <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 Di - <br /> i J4. r.. iTf 44 14 <br /> Job Address City _ P Lot Size PM <br /> Owner's Mame /' Address ` I & Phone <br /> Contractor �"� L Address h License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-9-- <br /> PUMP INSTALLATION Elft SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAR 'St IC TA NK LINESDISPOSAL FLD. PROP. LINE <br /> ,.. � <br /> FOUNDATION GRI_GUL ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRQBL'EM AREA CO" 4 ON SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of WellsExcavatr Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Grav ack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ther ❑ Delta Depth�of Grout Seeaa y e of Grout v� <br /> ❑Irrigation --Approx. Depth ❑ Eastern Surface�Se I Installed by <br /> Repair Wor one ❑ Type of Pump H.P. �, State Work Done <br /> Well Desstructio'n_ ❑'"'W611tiameter Sealing Material (top 501 <br /> Depth Filler Material,(Below 501 e_- -• <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION11 STRON (No septic system permitted if public sewer is <br /> available within 200 feet.I <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: t i _ Water table depth ; <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> k <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: _�Well Foundation Property Line 1 <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." i <br /> The applicant qnAt call for al! u' d irrspections. Complete drawing on reverse side. <br /> Sign Title: Date: <br /> r FOR DEPARTMENT USE ONLY41. <br /> s <br /> Application Accepted by Date �v Area v r <br /> Pit or Grout Inspection by Date Final Inspection by Date d1 <br /> / PI y j <br /> Additional Comments: 0it <br /> i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 V 14anteca 823-7104 ❑ Tracy . <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., .O. Box 2009, Stk., CA 95201 + ] <br /> w _4+ 1 <br /> S <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMWNO. <br /> + EH t3-241REV.1/851 �� ° S'Q C! f T b" Y7- <br /> EH 14-26 <br />