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i. <br /> APPLICATION FOR PERMIT ' `- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA r k* <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES,i YEAR FROM DATE ISSUED <br /> f , (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 <br /> City: Lot Size PM <br /> Owner's Name Address Phone <br /> Contractor Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ v — DESTRUCTION ❑ <br /> PUMP IN ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION . AGRICULTURE WELL OTHER WELL PITS/SUy' PS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + <br /> ❑ Industrial ❑ Op'fn Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well <br /> Casing <br /> ❑-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal y Type of Grout <br /> i ""'-t ' p <br /> ❑ Irrigation --Approx. Deptt ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump r H.P. State Work Done <br /> * Well Destruction ❑ Well Diameter <br /> � Sealing Material flop 50') <br /> Depth Filler Material (Below 501 l 1 <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_vCommercial_ Other <br /> Number of living units: Number of'bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ x, Method of Disposal I <br /> Distance to;ne arest: Well Foundation Property Line <br /> � P <br /> LEACHING LINE ❑ Nod& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS A ` ❑ Distance to nearest: Well Foundation Property Line ' I' <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin far whiccounty ordinances, state laws, and <br /> rules work and regulations of the San Joaquin Local,Health District. -- is { <br /> Home owner or licensed agent's signature certifies the following: "I certify that in�the performance of the h this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workmaRg compensation laws of California." Contractor's rhiring or sub-contracting signature I <br /> certifies the fallowing:"I certify that in the performance of the work for which this I ermit is issued,' I shall employ persons subject to:workman's compensa- <br /> tion laws of California.' AA v <br /> The applicant must call for all required inspections. Complete drawingon-reverse side. <br /> 'Signed X A __4eTit <br /> _Date: <br /> F D USE ONLY <br /> •- 1 <br /> App,cation�pt <br /> Date •�� Area <br /> i .t+ it or Giout}innspec y 3. Date M Final In pection by Date <br /> Additional Comments: a <br /> a` `t ❑ Stll 466-6781 I"'d Lodi 3'W_362'1`1~4, ❑ Manteca 8237104 ❑ Trac' 836-6385 i. 3 <br />'k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f - <br /> I�w INFO *' AMOUNT DUE AMOUNT REMITTED CASH RECEIVED'BY DATE PERMIT NO. <br /> w. <br /> + EH 13-24•IREV7H5i '�--- <br /> EH 14-28 <br />