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ti <br /> APPLICATION FOR PERMIT 3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE.,- STOCKTON, CA <br /> Telephone (209) 466-6781 4 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED , <br /> (Complete in Triplicate) <br /> i <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 i <br /> Local Health District. .-J <br /> , �' - • , <br /> _ �u 1 :f <br /> Job Address *� ' -- City [/� Lot Size FM <br /> �s � <br /> Owner's NameL// �+�- / Address Phone <br /> Contractor 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 FLD PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial �❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications h <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation y �pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pumpt H.P. State Work Done h { <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> ( Depth ` Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is (fin <br /> available within 200 feet.) J <br /> Installation will serve: Residence_� Commercial Other <br /> Number of living units: Number of bedrooms '~ <br /> F <br /> Character of soil to a depth of 3'feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments v } <br /> PKG. TREATMENT PLT. ❑ �`�. Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ; <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line i <br /> v <br /> SEEPAGE PITS ❑ Depth I Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line r <br /> DISPOSAL PONDS ❑ F <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 wdrk 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:").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. !- . - -- �^ 7t <br /> The applicant muI talrF6r all requ'ed'ns ions�omplete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY �4 <br /> Application Accepted by Date `� y Area ) <br /> Pit or Grout Inspectionby Date Final Inspection by Date <br /> Additional Comments:",,,` � �-�'`� <br /> P <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4euae_Alezxj <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,1Pv.OrY..B,ai2P_lrr- <br /> A50} 92 <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24(REV.r i e 5) <br /> £H 1428„ • ._. G1 <br /> i <br />