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t <br /> t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> j (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. <br /> Job Address / f • i r� <br /> City ,?fib Lot Size /i/� PM <br /> i / �j <br /> F Owner's Nam - Address `yyy P17 w—, Phone <br /> Contractor's Name4License No. �L�'3 l� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> R PUMP INSTALLATION Ki SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE x <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> l <br /> 5<Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications _ <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by r <br /> ( <br /> Repair Work Done ❑ Type of Pum V8 �n <br /> I P YP P s' � H.P. _ /� State Work Done _1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 50') <br /> ` TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Et available within 200 feet,) <br /> I Installation will serve: Residence_ Commercial 4 Other <br /> Number of living units: Number of bedrooms <br /> i Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposals <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED', ❑ Distance to nearest: well Foundation Property Line <br /> 17 <br /> SEEPAGE PITS ❑ Depth E.rs Size Number P <br /> SUMPS ❑ Distance to nearest: { Well Foundation Propeity Line'_ <br /> DISPOSAL PONDS ❑ W 4,�, s <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 /> 's <br /> 5 employ any person in such manner as to become subject to workmancompensation laws bf 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 rftst cali for all -aqui- dins tions. Complete drawing on reverse side. / <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date (/— w Area Q[>✓ <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 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE <br /> I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> 1s <br /> f + EH 1426(REV,10!831 z , �� ti�'�Z % B <br />