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i <br /> APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZELTON 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 r <br /> .City ' <br /> Lot Size PM <br /> Owner's Name Q <br /> C�� Address <br /> r ; Phone <br /> Contractor ��.` <br /> Address .� <br /> TYPE OF WELL/PUMP: NEW WELL E3% License No. Phone <br /> WELL REPLACEMENT ❑ Y DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEARESTFNSEPTIC TANKOTHER Elr <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> "FOUNDATION AGRICULTURE WELL <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CJ Industrial ❑ Open ❑ <br /> Bottom t <br /> Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> ❑ Public Type of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation ---Approx. Depth El Eastern Type of Grout <br /> Repair Work Done ❑ T Surface Seal Installed by <br /> Type of Pump � H.P. <br /> Well Destruction ❑ Well DiameterState Work Done D <br /> Sealing Material atop 50'} <br /> Depth <br /> ' Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 11Vo septic system permitted if public sewer is <br /> Installation will serve: Residence— available within 200 feet.} <br /> Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Type/Mfg Water table.depth <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> r <br /> Distance to nearest: Well Method of Disposal <br /> i <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Total length/size n <br /> "Foundation Property Line 'r�A <br /> SEEPAGE PITS ❑ Depth <br /> Size Number <br /> SUMPS ❑ Distance to nearest: Well <br /> DISPOSAL PONDS F1Foundation Property Line t <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 performance of the work for which this <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 permit is issued, I shall not <br /> i <br /> tion laws of California." p y persons subject to workman's compensa- r <br /> The applicant u Co call for all required i tions. fete drawing on reverse side. <br /> AZ <br /> Si <br /> Title: <br /> Date: <br /> ate: fY r/ I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ L� <br /> Date Area 4L—� <br /> Pit or Grout Inspection <br /> Date Final Inspection <br /> Additional Comments: Y� ��d Date <br /> - <br /> ❑ Stk 466-6781 q Lodi 369-3621 ❑ Manteca 623-7104 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazelton Tracy A e., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO S iRECEEIVEDBY DATEPERMITNO. <br />+ EH 13-24 IREV.t i s s5 �-0 <br /> EH T428 V <br />