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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T 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 Sgn 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 Distric . <br /> Job Addres,s <br /> City Lot Size /¢� PM ., <br /> Owner's Name <br /> Address Phone / 6 �J <br /> Contra ctor,b 1'�1 C Address �� License No.?O S7sZ f Phone 4✓ <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 /> FOUNDATION AGRICULTURE WELL 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 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ­ <br /> I I irrigation Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Welt Destruction ❑ Well Diameter Sealing Material (top 501 A <br /> PIN— Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.) REPAIR/ADDITION DESTRUCTION I t (No septic system permitted if public sewer is <br /> available within 200 feet.),' j <br /> Installation will serve: Residence Commercial Other t I <br /> Number of living units: ---LNumberof bedrooms._.,_ <br /> y <br /> Character of soil to a depth of 3 feet:i.. - Water table-depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity -No. ComP artments <br /> PKG. TREATMENT PLT. LlMethod of Disposal <br /> " Distance to nearest: -Well Foundation Property Gine = <br /> LEACHING LINE LT--No. & Length of linesTotal length/size <br /> FILTER -3BED ❑' Distance to nearest: Welt '` Foundation -1 Property Cine '70 <br /> SEEPAGE PITS I.YDepth Sire _ 1 Number <br /> SUMPS `" <br /> Distance to nearestr <br /> We &L6-) Foundation - property Line Q <br /> DISPOSAL PONDS ❑ -^'1 r <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, an <br /> rules and regulations of the San Joaquin Local.Health DRitrict.'.+ <br /> Homeowner or licensed agent's signaturecertifiesthe following:t"I-certify that in the performance of the work for which this permit is issued, I shall <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 applicarl must call f all quired inspections. Complete drawing on reverse side. <br /> Signed X < <br /> g Title: AXA01 <br /> FOR DEPARTMENT USE ONLY <br /> Ap lication Accepted by Date Area <br /> Pit r Grout Inspection by Datei <br /> Final Inspection by ate <br /> Additional Comments: <br /> ❑ Stk 466-6781 O Lodi ..369-3621- O 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 AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMIT'No. <br /> +,EH 13-24(REV.t i x 51 <br /> EH 11-28 <br /> I <br />