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s, <br /> APPLICATION FOR PERMIT � > �: <br /> SAN JOAQUIN LObAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 20 <br /> Telephone <br /> l p I 91 46fi-6781 <br /> PERMIT EXPIRES 1 YEAR 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 IWp sirltaes bed. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the application <br /> is <br /> Local Health District. ! , <br /> aquin <br /> Job Address {,( II J <br /> Cit r► V Lot Size PM 1 <br /> Owner's Name i <br /> Address 9 <br /> „ Phone <br /> Contractor—IRgLMM'p—s—Address ' C!- <br /> r J�License No. ,��— Phone <br /> TYPE OF WEL /PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION $A SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �1 <br /> DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 11 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation <br /> Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack <br /> ❑ Tracy Type of Casing <br /> i`1 Public f] Other Specifications <br /> ❑ Delta Depth of Grout Seal <br /> f I Irrigation Type of Grout <br /> —.-Approx. Depth Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction 11 Well Diameter State Work Done <br /> Sealing Material (top 50') <br /> Depth. Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.7 REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other r available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: i <br /> SEPTIC TANK ❑ Water table depth <br /> . Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Capacity_ No. Compartments <br /> Distance to nearest: Well Foundation Method of Disposal <br /> Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Distance to nearest: Well <br /> FILTER BED Total length/size <br /> ❑ Foundation <br /> Property Line <br /> SEEPAGE PITS I'] Depth Size <br /> SUMPSNumber <br /> L7 Distance to nearest: Well Foundation Property <br />—"41"DISPOSAL-PONDS' P ttY Line <br /> . I-hereby certify that I have prepared this application and that the work will done in accordance with San Joaq <br /> rules and regulations of the San Joaquin Local Health District. uin county ordinances, state laws, ander <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."Contractors 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 ust call r all required inspections. Complete drawing on reverse side. <br /> I <br /> Signed X <br /> Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by JZJ <br /> Date e <br /> Pit or Grout Inspection by bate c � <br /> by Date <br /> Additional Comments: Final Inspection <br /> T <br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104, ❑ 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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> �^ CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV,i i K s) <br /> . EH 14-28 <br /> b QPYI <br />