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7 .4 <br /> APPLICATIO).y FOR PERMIT <br /> SAN JOAQUIN LOC L HEALTH DISTRICT f <br /> 1601 E. HAZE:LTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67.81 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUIED. <br /> (Complete in Triplicate). <br /> Application is hereby made to the San Joaquin Local Health District far a permit to construct and/or install the work herein described:This•application is <br /> made H 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 �r;1 <br /> City Lot Size_�� . f .PM <br /> Owner's Name I ddress <br /> ` �_� Phone �Contractor's Name Name �- License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK U OTHER ❑ ` -a <br /> SEWER LINES DISPOSAL FLD. PROP• LINE <br /> FOUNDATION _ AGRICULTURE WELL <br /> OTHER WELL � PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Domestic/Private ❑ Gravel Pack ❑ Trac Dia. of Well Casing <br /> ❑ Public � y TYPO of Casing Specifications . <br /> ❑ Other. ❑ Delta Depth of Grout Sea! <br /> ❑ Irrigation ---Approx. Depth Eastern Type of Grout <br /> Repair Work Done Type of Pump Surface Seal Installed by - ..� �_ Op <br /> H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top-50'} i <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION L7 (No septic system permitted if public sewer is <br /> I I #vailable 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: <br /> SEPTIC TANK -Water table depth <br /> ❑ Type/Mfg Capacity_ `'- ! I <br /> PKG. TREATMENT PLT. ED ' No. Compartments <br /> i ) I Method of Disposal <br /> t:Distance to nearesWell Foundation f "� <br /> —, _ - — Property Line <br /> LEACHING LINE ❑ No. & Length of lines _. ~ T �1- <br /> FILTER'BED Total length%size-- _ A <br /> ❑ Distance to nearest: Well x ll x 'g"- <br /> Foundation Z <br /> Property Line <br /> SEEPAGE PITS ❑ Depth 1 Size <br /> SUMPSNumber <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS F1 Foundation Line <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 <br /> tion laws of California." ' p p y persons subject to workman's compensa- <br /> tion <br /> ap mu call for all req ' tnspeati s. Compl drawing on reverse side. y <br /> Signed <br /> Title- <br /> l. Date: <br /> f l FOR D ARTMENT USE ONLY <br /> Application Accepted by Z� Z �� <br /> Date Area k <br /> Pit or Grout Inspection by Date <br /> ��. Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 Cl Lodi 369-3621 , ❑ Manteca 823-7104 L1 Tracy 835-6885 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 — <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE - <br /> PERMIT"NO. <br />+ EH 13-24{REV.101831 <br /> EH 1428mt <br /> - fllf <br />