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r <br /> APPLICATION FOR PERMIT �.IY <br /> 'i SAN JOAQUIN LOCAL HEALTH DISTRICT vac <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I� (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 /> it <br /> Job Address .) <br /> City N Lot Size PM i <br /> Owner's Name Address e. Pnofir� <br /> i <br /> Contractor � AddressX 2 <br /> - License Phone• <br /> TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTiON?� <br /> AgZ7 � <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑O Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public O Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ IrrigationApprox. Depth Cl Eastern Surface Seal installed by <br /> 411 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth . Filler Material (Below 501 <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 Commercial_ Other <br /> Number of living units: 11 Number of bedrooms <br /> 6 <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. ❑ I� Method of Disposal <br /> I�Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> n <br /> i <br /> SEEPAGE PITS " ❑ II Depth Size' Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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: "f certif <br /> tion laws of California." y that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> it 1 <br /> The applicant m t call for all required ' spections. Complete drawing on reverse side, t <br /> i <br /> Signed +-w. Ii lie, <br /> Date: <br /> Title: <br /> ` <br /> �i FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> 2� <br /> Pit or Grout Inspection Date Final Inspection by Date" <br /> Additional Comments: C L- 4-c , J G r. -2 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 /> I� <br /> FEEO AMOUNT AMOUNT REMITTED K H RECEIVED eY PERMIT NO. <br /> + EH 13-24 REV.1/851 f i <br /> EH 1428 = Ij ,%� <br />