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1 <br /> APPLICATION FOR PERMIT <br /> l 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 /> (Complete in Triplicate) <br /> Application is hereby y 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. 1861 for well/pump and the Rules and R <br /> Local Health District Regulations of the San Joaquin <br /> y4i-Job Address weer e� City ' Lot Size v pM <br /> Owner's Name - <br /> Address,. <br /> Phone <br /> Contractor Address License No, t Y <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT ❑ DESTRUCTION L1 <br /> PUMP INSTAL TION ❑ STEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE <br /> i FOUNDATION <br /> AGRICULT RE WELL OTHER WELL PiTS/SUMPS � ' 1 <br /> t INTENDED USE TYPE OF'WELL PROB AR CONSTRUCTION SPECIFICATIONS j <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia.,of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel pack ❑ Tracy Type of Casing_ j, <br /> ❑ Public Specifications <br /> ❑ Other„ ❑ Delta De of Grout Seal Type of Grout Irrigation prox. Depth ❑ Ea nAp <br /> j <br /> Surface 1 Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done r <br /> Well(Destruction F) Well Diameter Sealing Material atop 50'1 <br /> Depth Filler Material{Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O DESTRUCTION ❑ (No septic system permitted f public sewer is € <br /> r available within 200 feet.) i <br /> Installation will serve: Residence `Commercial Others <br /> Number of livin unit T- N0n-h6 of-bedrooms <br /> ---- - 9- - -- - - - - - <br /> Character of soil to a tfeptH•ofa feet: t 1 <br /> Water table depth <br /> SEPTIC TANK ❑ "Type'/Mfg, Capacity No. Compartments. <br /> PKG. TREATMENT PLT. p Method of Disposal y <br /> s bistalca to nearest: Well-J vv„Foundation <br /> _ 2 Property Line <br /> LEACHING LINE Cr'�NO. & Length of lines - Total length/sizeZ <br /> i <br /> FILTER BED ❑ Distance to nearest: Well 1_D�`f� Foundation aQ Property Line ` <br /> J <br /> SEEPAGE PITS Depth Z- Size <br /> Number <br /> SUMPS ❑ Distance to nearest: ' Well Foundation Pro I <br /> DISPOSAL PONDS ❑ 3 party Line <br /> I hereby certify that I have prepared this appli tfon and`thet the work will be done in accordance with San Joaquin county ordinances,state laws and <br />!A. rules and regulations of the San Joaquin Local Health District! <br /> ? Home owner or licensed agent's signature certifies the foil owirip.: "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 sabjectTd"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 comperisa y' <br /> tion laws of California." <br /> The all plican must call fora required inspections.'Complete drawing on reverse side. <br /> Signed <br /> Title: Date ' <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Applica n pled by Date Area <br /> Pitor Proutinspectron � Date 3 3 8 Final Inspection by-. Date <br /> Y Additional Comments: <br /> ❑ Stkl3694621, <br /> 466-6781 ❑ Lodi 369 1. ❑ M n}eca'- 823-71 ❑ 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 />.�_ <br /> FEEAMOUNT DUE AMOUNT REMITTED CK <br /> F INFO CASH RECEIVED BY DATE PERMIT'NO.' <br /> 4 <br /> -77-7--7-.1 �. ... <br /> I +EH13?A(REV 1 <br /> /e57 <br /> EH 1428 <br />