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k <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE 18SUED <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 City <br /> LTJ Lot Size PM <br /> Owner's Name Address Phone <br /> —Contractor. ..,4,( L — Address ? Di C�r1 LicenserNop'Z_S:5� Phon j <br /> _.TYPE OF WELL/PUMP: _ NE,W WELL.❑ WELL REPLACEMENT:0 _'__ DESTRUCTION <br /> r - <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES ,DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well'Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`l Public,,.:-' F1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __Approx. Depth l I Eastern Surface Seal Installed by ' <br /> t <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'I <br /> Depth Filler Material 18elow 501 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITIONX DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> ayailabi`e.within 200 feet.) <br />{ Installation will serve: Residence inf- Commercial Other, j <br />+ Number of living units:, Number of bedrooms a, <br /> Character of soil to a depth of 3 feet: rf Water table depth <br /> SEPTIC TANK ,'di•;:. ❑ Type/Mfg ­Capacity-" �° " ',.:..: �. No. Compartments <br /> PKG. TREATMENT PLT. ; 4 � ,Method of Disposal <br /> Distance to nearest: Well Foundation, Property Line ' <br /> i <br /> LEACHING LINE t <br /> o. &Length of lines �. T 'Total length/size <br /> FILTER BED istance to nearest: Well }'foundation- Property Line s s <br /> SEEPAGE PITS Depth oC�� Size c3 'moi Number <br />+ SUMPS Ll Distance to nearest: well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that l 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. - I <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, 1'.shall employ persons subject to workman's compensa. <br /> tion laws of California.” <br /> The applicant must call fo"y requiLed inspections. Complete drawing on reverse side. <br /> Signed X� .Title: w bate: <br /> m <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date A ea <br /> Pit or Grout Inspection by Date Final Inspection by Date 3 0 <br /> I <br /> Additional Comments: <br /> Jr- � C) f <br /> ❑ Stk 466-6781 L] Lodi '369-3621 Q Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant - Return all copies to: Environhlental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. <br /> INFO CASH. <br /> ♦-EH 13-241REV. s) j15+ <br /> } EH 14-M' <br />