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i <br /> y <br /> APPLICATfON.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON SAVE., STOCKTON, CA <br /> 'Telephone (209) 466-6781 , <br /> n I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .1 ,. (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 SanJoaquin <br /> Local Health District.. f 4 ! <br /> PM <br /> 'C r <br /> CSize <br /> ity <br /> Job Address { I <br /> a- <br /> Owner's Name !r3 Address <br /> S Phone I <br /> �1 p �lC.Address ! C 4ti .License No. . Phone <br /> Contractor ' <br /> TYPE DF WELL/PUMP: NEW WELL d WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION (❑ SYSTEM REPAIR X'. OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> I PROP. LINE <br /> FOUNDATION E AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of CasingSpecifications <br /> li'Domestic/Private LJ Gravel Pack l 171 Tracy yp <br /> ❑ Public <br /> ❑ Other LJ Delta Depth of Grout Seal ;Type of Grout <br /> ❑ Irrigation ---Approx. Depth 0 Eastern S7! a Seal installed by <br /> Repair Work Done X Type of Pump <br /> H.P. <br /> State Work Done <br /> Well Destruction ElWell Diameter Sealing Material stop 501 tj} <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION 3 DESTRUCTION El (No septic system permitted if public sewer is <br /> k available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> 3 Water table depth^ ' <br /> Character of soil to a depth of 3 feet: r�> <br /> SEPTIC TANK El Type/Mfg "_Capacity Nb. Compartments <br /> - - Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line rt <br /> LEACHING LINE ❑ No. & Length of lines Toiai length/size u <br /> za <br /> , <br /> FILTER•BED ❑ Distance to nearest" � Well •-Foundation Pro`�� P�rtY,Line <br /> SEEPAGE PITS ❑" Depth r <br /> Size Number �f ' (j <br /> SUMPS Y. ❑ Distance to nearest: Well Foundation ° Property Line <br /> a DISPOSAL PONDS ❑ <br /> k will be done in accordance with San Joaquin county?ardinances, state laws, and <br /> I hereby certify that I have prepared this application and that the war <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 /> -contracting signature <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub <br /> l 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 /> If i <br /> tion laws of California." r <br /> The ap mus call for all require specti Co to drawing on rev side Ff <br /> r f Date: r <br /> Signed <br /> Title:' <br /> g <br /> i FOR DEPARTMENT USE ONLY / <br /> Application Accepted by <br /> �'///'j <br /> V� <br /> Pit or Grout Inspection by <br /> '.Abw -s Date" `VV `' Final<Irispection by Date (( <br /> Additional Comments: " <br /> ❑ Stk 466-6781 L3 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy $3x6385' <br /> it/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201Applicant- Return all copies to: Environmental Health Perm <br /> 6 <br /> FEE AMOUNT DUE" AMOUNT REMITTED CATRECEIVED BY DATE ;M17'NO, <br /> INFOEH 13-24 IREV.1/y 51 � <br /> EH 14-25 - -- <br />