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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I ON AVE.,,STOCKTON, CA <br /> G Telephone (209) 466-6781 A . <br /> PERMIT EXPIRES 1 YEAR FROM }DATE ISSUED n <br /> (Complete in Triplicate) <br /> r Application is hereby made to the San Joaquin Local Health District for a <br /> 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 /> Cl t <br /> E Job Address City Lot Size <br /> - PM <br /> Owner's Name 'S "Address111��� ^ <br /> � ���.� Phone ` <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION LJSYSTEM REPAIR Q OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. )PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 'PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack_ ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ___Approx. Depth ❑ Eastern Surface Seal Installed by y <br /> Repair Work Done ❑ Type of Pump _ e +H:P'- i State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth . a Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> _- <br /> Installation will serve: Residence_ Commercial available within 200 feet:) <br /> � Other <br /> a ) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:{ <br /> SEPTIC TANK �-Water table depth <br /> ❑ Type/Mfg Capacity ' No;.Compartments <br /> PKG. TREATMENT PLT. ❑ s <br /> Method of Disposal <br /> Distance t�o nearest: Well Foundation Property Line ` <br /> LEACHING LINE ❑ No. & Length of lines ; <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well -Foundation Property Line <br /> SEEPAGE PITS ❑ DepthSize <br /> Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared th7application 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." <br /> The applica t must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: k <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ` 2� �q <br /> Date Area V '` <br /> Pit or Grout Inspection _ Date Final Inspection Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 V 1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO C # RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-244REV,I/as) ,[ <br /> EH14-28 •C-,-5C) <br />