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6 <br /> F APPLICATION FOR PERMIT <br /> +- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 herein described. This 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 / �� 'r/Q JA I d� City Lot Size PM <br /> I <br /> Owner's Name Ca Address ►'�. Phone d f 3 0 <br /> Contract �.� Address License No. � Phone_ ` <br /> TYPE 0 WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑, DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL- f OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing j� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> * Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> --- <br /> i I Irrigation _Approx. Depth - I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. ' State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth Filler.Material (Below 50') �. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIRlADDITION 11 DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence— Commercial Other" <br /> Number of living units: Number of bedrooms <br /> Y <br /> 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 Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines k Total length/size', <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth 1 Size _ Number t <br /> SUMPS ❑ 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, state11aws, an <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 t <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 /> r <br /> The applicant must call for all required inspections. Complete drawing onr rse side. : <br /> n ^ b <br /> Signed X Title: l� —� Date: �` —7 <br /> R QEP RTMENT USE ONLY pp <br /> Application Accepted by 5AAA A6 • x, 1 1 Date "i7 Area <br /> Pit or Grout Inspectio by Date Final Inspection by -rT <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j <br /> Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> a EH 13-2!IREY.t/R 5) , 4,),'/ tibJ� - <br /> EH 14-26 `y <br /> 1 <br />