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a <br />� "tee <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 fol sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. `. <br /> t: 4 <br /> Job Address �`"� City Lot Size PM <br /> Owner's Nam <br /> !"�kddress l Phone <br /> i f <br /> t <br /> Contractor III Address # License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> 0. <br /> F0074Ehk N AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL P EA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca I Ion Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications <br /> I. <br /> ❑ Public ❑ Other u elm Depth of Grout Seal Type of Grout <br /> ❑ Irrigation epth ❑ Eastern Surface Seal Installed by --ClRepair Work Done ❑ pe of Pump H.P. State Work Done - <br /> l <br /> Well Destruction F-1WelliDiameter Sealing Material (top 501 6 <br /> Depth Filler Material (Below 501 I �Q <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION�(No septic system permitted if public sewer is <br /> 11 available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a deptOof 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 ❑ INo. & Length of lines Total length/size <br /> I FILTER BED ❑ t'6stance to nearest: Well Foundation Property Line, <br /> SEEPAGE PITS ❑ Depth 1 Size Number <br /> SUMPS ❑ 'Distance-to nearest: Well Foundation Property Line <br /> ` DISPOSAL PONDS ❑ I <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 /> k rules and regulations of the San Joaquin Local Health.District. -,--F - <br /> F 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."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 must call for all required i s io S. Complete drawing on reverse side. <br /> Signed 'le: Date: ��0 <br /> �p. FOR DEPARTMENT USE ONLY {� '.- <br /> Application Accepted by y � r ate l©— `j� Area <br /> �II . <br /> Pit or Grout Inspecti n by II Date Final Inspection by Date <br /> 14. 11L <br /> Additional Comments: -'�-v Gly <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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> 4.28 <br /> +'EH13-24fREV.t/s51 <br /> I <br />