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ti l <br /> v <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA— <br /> Telephone <br /> ._ <br /> Telephone (209) 466-6781 i <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 sewa_ge or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> w <br /> Local Health District. <br /> t C ef <br /> Job Address City Lot Size PM <br /> Owner's Name Address <br /> c�z cz Phone <br /> ' Contractor Address 5-- _License Na.� �/ Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 _ 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 SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE NS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of cavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack C3 Tracy ype of Casing Specifications <br /> f 1 Public C1 Other �thl <br /> a Depth of Grout Seal Type of Grout <br /> --- <br /> [1 <br /> 1 1 Irrigation _ Appro tern Surface Seal Installed by <br /> Repair Work Done ❑ - e-of Pump W.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material-Itop 501 <br /> I 1 Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION II1 DESTRUCTION (No septic system permitted if public sewer is <br /> a <br /> -available within 200 feet.I <br /> Installation will serve: Residence. Commercial Other <br /> Number of living units: 1 Number of bedrooms I <br /> Character of soil to a depth!of 3 feet: Water table depth <br /> SEPTIC TANK ❑ IType/Mfg Capacity�� No. Compartments <br /> t PKG. TREATMENT PLT. 11Method of Disposal <br /> t~ � <br /> Distance to nearest: Wel! ,Foundation Property Line <br /> f LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundations Property Line <br /> -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. <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 <br /> ignature- <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 /> 1 tion laws of California." <br /> The applicant m call for all required inspections. Complete drawing on reverse sid i <br /> lfes/ �J _— Date: <br /> Signed X � Title: � T _ . <br /> i OR DEPARTMENT USE-ONLY <br /> Application Accepted by Z A A, <br /> Date Area <br /> Pit or Grout Inspection by D Final IIDs tion by Date . <br /> Additional Comments:` <br /> ' 9 ❑ Stk466-678 ❑ Lodi'369-3641- ❑ Manteca 823-7104 EJ Tracy 835-6385 <br /> Applicant - Retur all copiew o: Enviro ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - <br /> f F <br /> I OUNT DUE AMo6NT REMITTED ASH RECEIVED BY ; DATE*.., PERMIT ND. <br /> _ <br /> + EH 13.24 IREV.t!K 5) +d0-0 � <br /> f <br /> EH 74d 5 .i e _ _ - <br />