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s <br /> APPLICATION FOR PERMIT <br /> SAN iOAQUIN 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 4 City Lot Size 160 xPM <br /> aAA <br /> Owner's NameReymA N/'tjw__eJ,&s AddressJ14Phone <br /> d 9A <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 r <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i <br /> ('1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ! <br /> N <br /> I I Irrigation Approx. Depth 1 1 Eastern Surface Seal Installed by F <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> r <br /> Well Destruction ❑ Weil:.Diameter Sealing Material (top 501 l <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is qhs <br /> � available1p <br /> Installation will serve: Residence_ Commercial_ Other �� within 200 feet.) <br /> Number of living units: Number of bedro ms 2 <br /> Character of soil to a depth of 3 feet: Water table depth �. <br /> SEPTIC TANK ❑ Type/Mfg �apacity No. Compartments ff <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ' <br /> Distance to nearest: Well Foundation _ Property Line/f�D <br /> r <br /> If <br /> LEACHING LINE ❑ No. Length of lines /� Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation��� Property Line /400 <br /> SEEPAGE PITS l I Depth Size _ Number <br /> 'SUMPS11 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin count ordinances state laws and 1 <br /> Y p p pP 4 Y <br /> rules and regulations of the San Joaquin Local Health Di1trict. <br /> Home owner or licensed agent's signature certifies the folli Wing: "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 call for all r ulYed inspections omplete drawing on rev a side. <br /> Signed /Z, <br /> `RAOf Title: Date <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by Date Area / <br /> Pit or Grout Inspection by Date Final Inspection by Date �2 <br /> Additional Comments: 1 <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 /> t ' <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. <br /> +.EH 1324(REV.i/H 5f <br /> EH 14-29 <br /> .I <br />