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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 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 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 <br /> r City Lot Size ! PM <br /> i T Owner's Name l � �� Address Phone <br /> Contractor 7 Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial i❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i Ll Public ❑ Other t 6-�O-Deita- - -Depth of-Grout,Seal— Type of Grout <br /> ❑ Irrigation __#pprox. Depth ❑ Eastern Surface Seal.lnstalled by <br /> Repair Work Done ❑ Type of Pump ' H.P, State Work Done <br /> I Well Destruction ❑ Well DiameteF Sealing Material (top 501 <br /> Depth Filler Material (Below,501 ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION r REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> t , available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: J_ Number of bedrooms <br /> Character of soil to a depth of-3 feet: h� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg_ { Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 3 z I 6X71 ! Method of Disposal ` <br />�. Distance to nearest:-» Well r�- foundation Property Line .__._ <br /> . r <br /> LEACHING LINE No. & Length of lines _Totfl length/size <br /> 1 :rte <br /> FILTER BED ❑ Distance to nearest: Well 0 Foundation Property Line 1 <br /> SEEPAGE PITS 91 Depth 5ii�= = "'' Number <br /> ' SUMPS ❑ Distance to nearest: Well oundationProperty Line ^, 6d <br /> 4 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. ' t . <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 applicantmust fgnreq e i pections. Com le rowing on, verse side. <br /> Signed Title: Date. <br /> FOR DEPARTMENT USE ONLY <br /> Tib �l <br /> j Application Accepted by Date Area <br /> Pit or Grout Inspection by Date { Final Inspection by Date 4/a% <br /> 1 p l <br /> Additional Comments:lLU1 M �i f BGr ivy �n�lA �d -C�U o (lY*` ' C D e f L5 D'7 3�i C/vG <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 „ ❑ Tracy 835-6385 Q 3��i� xfls <br /> C Applicant- Return all copies to: Environmental Health Permit/Services le01 E. Hazelton Ave., P.O. B&ox 01 <br /> FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT`NO. <br /> r INFO <br /> +'EH 13-2A I REV.i/a5) C 0 , V ULk,( (� (� $U <br /> EH 1420 J <br />