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f . <br /> -Z- <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 /> 5a ( � <br /> Job Address � - _ ' City' Lot Size PM <br /> Owner's Name I Address <br /> Phone <br /> Contiactor Address _jt,�. License No. Phone_ <br /> TYPE OF WELL/PUMP:. NEW WELL.❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ _ SYSTEM REPAIR C1 _ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> = FOUNDATION.___-. _ -AGRICULTURE WEL - -*OTHER WELL.. <br /> ELL. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL AREA CONS RUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack 0 Tracy 7 pe of Casing specifications <br /> f'l Public Cl Other r Cl Delta epth of Grout Seal Type of Grout _ <br /> I I Irrigation <br /> --Approx. Depth 11 Eastern Su ce Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P State Work Done <br /> Well Destruction 0 Well Diameter Se ling Material (top 501 <br /> Depth Filler Material (Below 50'►� 7w <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i] REPAIR/ADDITION f_I DESTRUCTION INO septic system permitted if public sewer is <br /> IIVailable 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: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 'Capacity i No. Compartments <br /> PKG. TREATMENT PLT. ❑ { <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> a• <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Welt Foundation <br /> I Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t have prepared this application and that the work will be'done in accordance with San Joaquin county ordinances, state laws, and f <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." n <br /> The applicant ust call for all r ired inspections. Complete drawing on r arse side. <br /> Signed X ,T.itle:_ Q <br /> - Date: <br /> FOR DEPARTMENT USE ONLYC�L VN <br /> � <br /> 1 <br /> Application Accepted by —ACkA(J\LJ1 <br /> Date 21 ,Area <br /> t <br /> Pit or Grout Inspection by Q Date EFinalspection by Date N <br /> Additional Comments: !J 1 <br /> ❑ Stk 466-6781 0 Lodi 369-3 0 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 /> f <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED <br /> INFO I ASH BY DATE PERMIT'NO. <br /> EH 14- <br /> + Eli 14 2f1 <br /> 24 f REV.1/K 51 <br /> _ r r <br />