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p! <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. �r /� <br /> Job Address.. _ Gt.Pv /�_. City ` Lot Size PM <br /> Owner's Name,> -- �L�l�! �U�u AWeIllfCAcidress Phone <br /> Contractor's Name 1 ? License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑` WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> a <br /> FOUNDATION — AGRICULTURE WEAL 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 r� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications a <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---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 ! <br /> Depth Filler Material'(Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is A <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: /1 Number of bedrooms -3 _ f <br /> Character of soil to a depth of 3 feet: a Water table depth &1,4111 <br /> r <br /> SEPTIC TANK 0"'Type/Mfg &W,&_ Capacity &4AV No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation !T Property Line S �� <br /> LEACHING LINE No. & Length of lines — {{ _T.otal length/size / � � <br /> FILTER BED IDDistance to nearest: Well 0 Foundation Property Line T <br /> ^ / I <br /> SEEPAGE PITS ❑ Depth a Size Number .� <br /> SUMPS 9�'Distance to nearest: Well Foundation � Property Line _LEr <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:"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 mus"all for all required ' pections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 9 r _ Area�-��� <br /> 6Pit r Grout Inspection by date Final Inspection by "" Date <br /> Additional Comments: <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK 0 <br /> CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-241REV. 101831 <br /> EH 1428 1 "t <br />