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APPLICATION FOR PERMIT c, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> F Telephone 12091 466-6781 <br /> f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �«. <br /> {Complete in,Triplicate} � -.r 4 <br /> '-t' ill r <br /> Application is hePLby 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 H 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, k: <br /> Job Address <br /> p r City Lot Size 1,66 pM. <br /> `Owner's Name � 4 <br /> T Address Ile, / - <br /> Phone <br /> Contractor Address <br /> YPE OF WELL/PUMP: License No, Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ ��, SYSTEM REPAIR ❑ OTHER ❑ s+ <br /> DISTANCE TO N SEPTIC TANK SEWER LINES <br /> �>._. DISPOSAL FLD. PROP, LINE <br /> FO ON AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br /> INTENDED USE �^"- TYPE OF WELL` _ LEM AREA CONSTRUCTION SPEOFICATIONS— <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> F ❑ Domestic/Private ❑ Grave' Pack Dia- of Well Casing <br /> ❑ Tracy Typ sing Specifications <br /> ❑ Public ❑ Other _� ❑ Delta Depth of Grout l <br /> ❑ Irrigation Type of;Grout 1 <br /> Type❑ Eastern Surface Seal Installed by i <br /> Repair Work Done C] Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ -Well Diameter <br /> I Sealing Material (top 50') <br /> Depth F Filler Material (Below 50') I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO fNo septic system permitted if public sewer is <br /> a <br /> Installation will serve! Residence_ -available within 200 feet:] <br /> Commercial Other ; t <br /> Number of living units: Number of bedrooms <br /> Character of soil to al depth of 3 feet: i <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT. El No. Compartments <br /> Method of Disposal s <br /> Distance so nearest: Well Foundation. Property Line <br /> LEACHING LINE ❑ Length of lines <br /> 1 <br /> FILTER BED L1 Distance <br /> length/size <br /> Distance taEnearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth # Size f <br /> SUMPSNumber <br /> ❑ Distance to 111nearest: Well Foundation <br /> DISPOSAL PONDS ❑ [ Property Line <br /> 1 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 must call for all required`inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: F 7 } <br /> Date: �' i <br /> FOR DEPARTMENT USE ONLY 11 <br /> Application Accepted by Date_ <br /> �,7 Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date 44J ) 1 <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 INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY jDATE PERMIT"NO. <br /> + Eli 13-24 fR[V.5/x s7s- <br /> EH 14-28 �C! <br />