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APPLICATION FOR PERMIT r <br /> " SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 heieby 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.[ 9A-41�— <br /> Job Address T ity Lot Size PM <br /> Owner's Nam Address Phone <br /> QConttaclo �4 ess (cense No. Phone <br /> TYPE OF WELL/PUMP: w NEW WEL ❑ ELL REPLACEME ❑ DESTRUCTION ❑ <br /> PUMP INSTAL4;W <br /> SYSTEM-RE1AR ❑ -- OTJ-iEF} ❑ I <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 SPECIFIC TIONS �f <br /> ❑ Ind strial ❑ Open Bottom 171 Manteca Dia: of Well Excavation Dia. of Well Casing <br /> mestic/Private ❑'Gravel^Pa.ckfi— ❑ Tracy Type of Casing Specifications -7k,­ <br /> ': <br /> y <br /> M Public n,Other EI Delta Depth of Grout Seal f Type of Grout 19._ <br /> I I Irrigation ---Approx. Dept i I Eastern surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter !I Sealing Material (top 501 _ T <br /> Depth I Filler Material (Below 50') _ <br /> TYPE OF SEPTIC,WORK: NEW INSTALLATION I REPAIR/ADDITION I 1 DESTRUCTION l I INo septic system permitted i f piblic sewer is <br /> -. available within 200 feet.) - <br /> Installation will serve:Y Residence _Commercial Other <br /> Number of living units: Number of bedrooms S <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments J <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation —--Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size r <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS Ll 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 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 persons subject to workman's'compensa- <br /> tion laws of California." <br /> The applicant u t all for II re i d ins ctions�Complete drawing on reverse side. <br /> r <br /> Signed X Title: Date: <br /> F R DEPARTMENT U5E ONLY <br /> Application Accepted by Date � y� V Area <br /> Pit or Grout Inspection by / Date(=} �-- Final Inspection by -'Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104' ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE +,[�;► <br /> INFO AMOUNT DUE AMOUNT REMITTED CCK 4 <br /> ASH RECEIVED BY DATE PERMIT'NO. <br /> + EH13-24(REV.1/K5) `�+� ��?-1S-L3 <br /> EH 14-26 ��� ! 1�/ o O— SZ <br />