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APPLICATION FOR PERMIT - - - --. <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> R <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 /> r �/ <br /> Job Address City Lot Size d /' � PM <br /> Owner's Name Address Phone <br /> Contractor's Name License No.C:;; CZ1Pbone �77 <br /> TYPE OF WELL/PUMP: NE ELL ❑ WELL REPLACEMENT ❑ DESTRUCTi <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 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by "t ttr <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done Q <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION JK iNo septic system permitted if public sewer is <br /> vailable within 200 feet.) i <br /> installation will serve: Residence_ Commercial_ Other T. <br /> Number of living units: Number of bedrooms 2-6 0 <br /> Character of soil to a depth of 3 feet: Water table depth�r Z <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 ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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."Contractors 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 foralluire inspec i s. Complete drawing on reverse side. <br /> Signed ` L ills: Date: <br /> p FOR DEPARTMENT USE ONLY Q <br /> Application Accepted by Date [ rZ-%; Area <br /> Pit or Grout Inspection by Date Final Inspection by 64 014 Date <br /> Additional Comments: _ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CKA 5 RECEIVED BY DATE PERMIT"NO. <br /> v <br /> +EH 13-24(REV.10/83) �..4a <br /> EH 1426 Q..� �f a� Ll-42,.�b <br />