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S <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 £o <br /> City t sly'^—P�•Lot Size PM <br /> Owner's Name <br /> Address Phone <br /> Contractor G Address q Ow License No. hone �• <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 U$E TYpE OF WELL-_'--PROBLEM AREA "-CONSTRUCTIOWSPECIFICATIONS <br /> ❑ Industrial ❑ Open-Bottom ❑ Manteca <br /> NO. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ID Gravel Pack p Tracy Type:-of Casing ° Specifications <br /> i 1 Public a ❑ Other 7 <br /> t 1;Delta Depth of Grout Seal Type of Grout _ <br /> kr.. <br /> I ] Irrigation �,-Apprax. Depth 11'Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter iSealing Material (top 50') <br /> Depth Filler Material 10elow 50'1 <br /> TYPE OF SEPTIG.WORK: NEW INSTALLATION I:1, REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: ResidenceL Commercial Other <br /> Number of living units: Numberofbedrooms_ ' <br /> Character of soil to a depth of 3 feet:.. <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ~f ' Capacity No. Compartments <br /> PKG- TREATMENT PLT. ❑ �.. Method of Disposal <br /> Distance to riga Est: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size i <br /> # Number <br /> SUMPS Ll Distance to nearest: Well Foundatitin Property Line <br /> DISPOSAL PONDS ❑ — f <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 "'employ an � �'~-•-••=- � fY performance of the work for�uihicli this permit is'is"s�ed, I shall not <br /> p y y person in such manner as to become subject to workman's ciimperisation 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 ibis permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of California." - , I <br /> f <br /> The applicant must call for al requi ed inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: 1214— <br /> r r <br /> L FOR DEPARTMENT U,SE ONLY <br /> Application Accepted by i Date / r r -A- <br /> Area r i <br /> i <br /> Pit or Grout Inspection tDate al Inspecti by ! �il� Date <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 /> FEE - AMOUNT'Dt1E - K-AMOUNT'REMITTEDINFOASH - RECEIVED-BY 'DATE - --PERMIT`NOr- <br /> +.EH 13-241REV,rin5l -_••.- <br /> EH 14-28 �j - <br />