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1 <br /> } APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FI: <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> _ Telephone (209) 466-6781 <br /> PERMIT EXPIRES Z YEAR FROM DATE ISSUED <br /> {Com Tete in Triplicate) <br /> R t' <br /> i 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 welilpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 77 �� City f > Lot Size PM <br />` Owner's Name Address Phone / <br /> AContractor � r Address License No.12Phone <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 /> l F`l Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout <br /> - <br /> I I'Irrigation —..Approx. Depth i I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> + Well Destructicin ❑ Well Diameter Sealing Material (top 501 <br /> e t Depth Filler Material (Below 50') <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION i DESTRUCTION i I (No septic system permitted if public sewer is <br /> I / available within 200 feet) [7 <br />! Installation will serve: Residence`� Commercial— Other i <br /> !!! I <br /> -- Number of living units: Number of bedrooms 3. <br /> I Character of soil to a depth of 3 feet: ��/7'L t Water table depth <br /> SEPTIC TANK ❑ Type/Mfg f L Capacity No. Compartments <br /> i Method of Disposal <br /> PKG. TREATMENT PLT. ❑ .� r l <br /> Distance to nearest: Well �_ Foundation e� Property Line <br /> kf C <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ' (�*� <br /> FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line_4:�.67.` T <br /> I l <br /> s SEEPAGE PITS l I Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. ., <br /> r 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 /> I The applicant must call for all required inspections. Complete drawing on reverse side. <br /> E ! <br /> i <br /> SignedX-. Title: _ ,d Date: [ /-/If/ <br /> Y 7­ <br /> /FOR 00ARTM -NT U E ONLY .. v 1 <br /> Application Accepted byf�f Date Area <br /> r <br /> Pit or Grout Inspection by Date '/ Final Inspection by�`/�'�' �� � Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 <br /> Applicant - Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE K 4 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. <br />` �+ EH i3-24IHEV.t/w5f Q <br /> EH 1426 1/q p <br />