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4 J <br /> /t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �p <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.• 1-1 <br /> Job Address +� City � Lot Size,&�xZ0Z7 PM <br /> Owner's Name Address' hL�! - Address Phone <br /> Contractorf &4�Address -2 License No..�.�4�Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (•.J <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i ^� <br /> INTENDED USE ,,-'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS lrti�' <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type ofrasing ~�? Specifications <br /> ❑ Public T,❑ Other ❑Delta ~ Depth of Grout Seal i Type of Grout 1 <br /> ❑ Irrigation f I---Approx. Depth ❑ Eastern Surface Seal Installed by ! <br /> Repair Work Done ❑ }Type of Pump H.P. ? State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 I �, <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted it public sewer is <br /> E , 1 available 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: Water'table depth <br /> SEPTIC TANK X Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ -----------Method of Disposal <br /> Distance to nearest: Well : Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines _ T Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number `t <br /> SUMPS ❑ Distance to neatest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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:-"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 applicant m Y call fr all required inspections. Complete drawing on reverse side. <br /> f <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY Q� <br /> Application Accepted by Date �.,`-' r Area <br /> Pit or Grout Inspection Date Final Inspection <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FES AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI-r NO. <br /> INFO CASH <br /> + EH 13za IREV.,ias, S ^'1 2� <br /> EH 1426 <br />