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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> - <br /> t t t . (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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 _ / ��. l �C! City Al Lot Size PM <br /> i I <br /> Owner's Name _.. �7T /V/fff 0_&Address Phone <br /> r � -- <br /> Contractor's Name /p' y License No. Phone s <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION SYSTEM REPAIR L7 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC,TANK.' :`° SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION '— AGRICULTURE WELL 'f—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 V <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surf 7:,, I Installed by <br /> Repair Work Done ❑ Type of Pump{ H.P. State Work Done <br /> h Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <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: Number of bedrooms <br /> t Character of soil to a depth of 3 feet: i Water table depth <br /> SEPTIC TANK ❑ 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 <br /> 4 <br /> SEEPAGE PITS ❑ Depth Size Number <br /> °SUMPS ❑ Distance to nearest: . _ .Well Foundation Property_Line.: <br /> DISPOSAL PONDS ❑ '' p <br /> d <br /> I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin`coun <br /> fY P P Ppty'-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-hlr ng or subF;ontracting 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 muW c II forII i inspections. o let°drawing on rev si ENVIR0MENTAL HEALTH <br /> Signed X Title: Date: <br /> F SPAR ENT USE ONLY <br /> Application Accepted by Date <br /> Q/1 �J A a <br /> Pit or Grout Inspection by Date Final Inspection by Date �� ' <br /> Additional Comments: _ ! <br /> ❑ Stk 466-6761 ❑ 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 1 <br /> INFO AMOUNT/D`�UE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT"NO.( <br /> + EH 1324{REV.101631 �U ,. / _ 1 J i <br /> EH 1428 Nv <br />