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3 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br />`r Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR 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 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. a 1 <br /> Job Address L City Lot Size PM <br /> h <br /> Owner's Name R Address Phone <br /> 'Contractor L Address ❑cens:35e No. -�Qa 2 Phone_ s <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. LINT= <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> s <br /> ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Specifications <br /> Type of Casing <br /> M Public Ll other C1 Delta Depth of Grout Seal Type of Grout <br /> --- <br /> I I Irrigation _.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> RIl'. <br /> � Repair Work,Done ' ,❑ -Type of Pump N.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> j s Depth Filler Material IBelow 50') <br /> TYPE= OF SEPTIC WORK: NEW INSTALLATION AIR/ADDITION 1 1 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> 1 <br /> i, Installation will serve: Residence L–�mmerciAl ther <br /> Number of living units: !Number ofedrooms_.y.,-7 1{ `yk, <br /> Character of soil to a depth of 3 feet: ! Water table depth <br /> SEPTIC TANK k '❑ Type/MfgC n w.r r Cap. ity 67'Compartments <br /> PKG. TREATMENT PLT. LJ Method of Disposal <br /> Distance to nearest: Well,( Foundation Property Line J ,� <br /> LEACHING LINE & Length of lines. Total length/size <br /> FILTER BED ❑ .Distance to nearest: Well Foundation Property Line' <br /> SEEPAGE PITS IVIL7epth _ Sizef # Number_ <br /> t SUMPS ❑ Distance to riearest: WeN Foundation Properly Line <br /> f t a ., f � , <br /> 1 DISPOSAL PONDS <br /> k I hereby certify that 1-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. r <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 /> s 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 /> I tion laws California." ! <br /> 1 The applican s call or It re ired i s cti late drawing on rp4erse si4e. 1 <br /> F' <br /> Signed Title: Date: <br /> .FOR DEP_ARTM.ENT._USE-.ONLY,,..-.;..-: — <br /> «. Application Accepted by VM� � �^ Data � ~ � Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: - <br /> ­ - <br /> AStk" 466-6781 ..r._ E Lodi 369-3621 '�~�❑ Manteca 823-7104 -❑ Tracy, 835-6385 <br /> pplicant Return all copies to: Environmental Health Permit/services 16014. tlazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED UN 4F CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO s- �7 <br /> + EH 13-24IREV.i/H51 <br /> EH 14.28 <br />