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i <br /> APPLICATION FOR PERMIT ^ <br /> 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -: 1601 E. HAZEL ION AVE., STOCKTON, CA r <br /> Telephone (209) 466-6781 <br /> MAY I � ���� PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> � I (Complete in Triplicate) <br /> j� l�;ilil l 15ERV C E� <br /> P Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install the work herein described.This application is <br /> made in complianRy- , y4A-;v <br /> 1. aquin County Ordinance No. 549 sewage o "��for well/pump and the Rules and Regulations of the San Joaquin <br /> r Local Health Dist �_/�® y � r �,f/"' 6 eCity CQI Lot Size �� MJob Address !I <br /> 7 � �' <br /> I !Ip C Address � d Q Phone <br /> Owner's Name <br /> �'� r�� Address `'� r License No', Phone <br /> ContractorTYPE OF WELLIPUMP: II NEW WELL WELL REPLACEMENT" Ll DESTRUCTION ❑ ' <br /> ..- P�!MP INSTALLATION 171 ` SYSTEM REPAIR ❑ OTHER ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES PITS/SUMPS- - s <br /> FOUNDATION AGRICULTURE WELL I OTHER WEL <br /> I INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRU�Ecava�ti �� <br /> r� <br /> Dia. of Well Casing <br /> ❑ ndustrial 0' pen Bottom ❑ Manteca" Dia. of Well a <br /> Type of Casing Specifications <br /> t pamestic/Private Gravel Pack ❑ Tracy 1 Type Of Grout <br /> F1 Public f111 Other ❑ Delta Depth of Grout Seal <br /> I !irrigation <br /> .Approx. Depth eastern Surface Seal Installed by ®Lt/N �� <br /> " <br /> H. H.P. State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> fir' Sealing Material (top 50'1 <br /> Well Destruction ❑ We11 Diameter 9 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: !NEW INSTALLATION 1.1 REPAIR/ADDITION E I DESTRUCTION I ] Mo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> I�'" <br /> Installation will serve: Re��sidence_ Commercial_ Other <br /> Number of living units: �_. Number of bedrooms <br /> ar Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑i Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑11! Method of Disposal <br /> { <br /> Foundation Property-Line <br /> Distance to nearest: Well , <br /> LEACHING LINE 01 No. & Length of lines Total length/size <br /> `i Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> aH Number ' <br /> SEEPAGE PITS l I Depth Size S <br /> ,I. Property Line <br /> SUMPS= -" L];_Distance to.nearest: Well__Foundation �_ , .,R <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 kaws, <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner of 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 /> bject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in suchl�manner as-to became su <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." 111, <br /> r The applicant 11 for all req a inspections. Complete drawing on r rse side. <br /> Signed X <br /> Title: Date: <br /> �I R DEPARTMENT USE ONLY <br /> Date `� Area <br /> Application Accepted by , <br /> Pit or rout Inspecti y <br /> Date, Final Inspection by Date <br /> aL � �- <br /> Additional Comments: u� Gam` <br /> ❑ Stk 466-6781 , ❑)Lodi 369-9621 El Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik„ CA 95201 <br /> I� <br /> FEEECIS RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO .� <br /> +.EH 13.24(REV.5 i x 5) �p <br /> EH 14.26 Y <br />