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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 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 _ _ t � IF City Lot Size PM 1 <br /> �) � �" 4 <br /> Owner's Name + /� Address � ,�>� Phone <br /> VAE <br /> Contractor S�& . Address ' <br /> License No. °Phoria" <br /> TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMEfJT ❑ DESTRUCTION �Y i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 4PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> EJIndustrial E3Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (-1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout ._. <br /> 1 1 Irrigation _.-Approx. Depth I i Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done {}�, <br /> Well Destruction Well Diam er Sealing Material It r <br /> t <br /> Depth Filler Material �""'I -- 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION I I DESTRUCTION { (No septic system permitted if public sewer is , <br /> l available within 200 feet.i I <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 ❑ 1' 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 Total length/size <br /> FILTER BED, ❑ Distance to nearest: Well Foundation Property Line i <br /> t <br /> SEEPAGE PITS I ] Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line " I <br /> DISPOSAL PONDS ❑ <br /> 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: "(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 t qOr ons. Complete drawing on raver ide. <br /> Signed X i!�� Title: Date: <br /> U <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date — Area c�� <br /> Pit or Grout Inspection by Date�O Final Inspection by Date r p b <br /> Additional Comments: i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 EAAanteca -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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EH13-241REV.)imro <br /> ER 14-28 <br />