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a <br /> tp� <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 /> S_4job Address City , at Size /Ox PM <br /> Phone <br /> XOwner's NameHdress <br /> GG 17� Oo se No. Phone <br /> Contractor � �Address <br /> TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REVIR ❑ OTHER C3 r <br /> SEWER LINES -- DISPOSAL FLD. PROP. LINE , <br /> DISTANCE TO NEAREST: SEPTIC TANK i <br /> FOUNDATION 2.-5-1_.- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ift/ Dia. of Well Casing ' r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing. �` �� Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ypType of Grouter <br /> nDelta Depth of Grout Seal ��� <br /> N Public ❑ Other WC✓ <br /> I 1 Irrigation — PP _ <br /> A rox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump Cr State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth — Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION I I iNosepti cystithin m permitted if public sewer is <br /> ava1 <br /> Installation will serve: Residence— Commercial— Other C1 <br /> Number of living units: Number of bedrooms ` <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Ca <br /> SEPTIC TANK LJ Type/Mfg <br /> pacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Wellndation Property Line <br /> LEACHING LINE Cl No. & Length"of lines Total length/size <br /> FILTER BER ❑ Distance to nearest: W <br /> Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that l 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 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." - N� <br /> applicant ust call for required inspections. Complete drawing on reverse side. <br /> The app� 3 (� <br /> [,Signed X Title: Date: <br /> r FO ARTAA ONLY <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout inspection by + Date 3 Final inspection by Date -I tis <br /> Additional Comments: <br /> ❑ Stk 466-6781 C] Lodi 369-3621 El Manteca f323 710A ❑ Tracy X55 Boz 2009 Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., f.O <br /> FEE CK RECEIVED BY DATE 4—E7 <br /> NO. <br /> INFO AMOUNT DUE UNT REMITTED CASH <br /> /rte o�+ EH 13-241REV.1/95) -j/ S <br /> EH U-2B (( <br />