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F <br /> � <br /> Jl. � <br /> " APPLICATION FOR PERMIT <br /> L HEALTH DISTRICT <br /> SAN JOAQUIN LOCA � <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA ^' n <br /> Telephone (209) 466-6781 �ti 13 w u <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F-NIVI omENTAL HEALTH <br /> (Complete in Triplicate) F�l�h1t:��CR�fl�E� <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 City Lot Size PM <br /> Job Address "" '1 <br />� y <br /> Address r Phone <br /> Owner's Names <br /> pr) f� .. � ,License No. ! W- Phone / [ <br /> Contract? - Address,l—'�`.,��ftD �` <br /> TYPE OF WELL/PUMP: ! NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION LJ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> Y <br /> DISPOSAL FLO.DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> w Type of Casing Specifications <br /> '�omestic!Private El Pack •❑ Tracy g Type of Grout <br /> FI Public (-1 Other n Delta Depth of Grout Seal - <br /> m <br /> I I Irrigation <br /> �..Approx. Depth I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of-Pump o,4.erdJEL7 H.P.��7r State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material atop 501 C>1 <br /> 4 t <br /> If Depth Filler Material (Below 50') <br /> WORK:. NEW INSTALLATION 11 REPAIR/ADDITION LI DESTRUCTION l I INo septic system permitted if public sewer is <br /> TYPE OF SEPTIC <br /> f available within 200 feet.) <br /> Installation will serve:, -Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑.r,'TypelMfg Capacity No. Compartments <br /> t PKG. TREATMENT PLT- nvrj Method of Disposal s <br /> w Distance to nearest: Well Foundation Property Line r <br /> � LEACHING LINE Cl ; No. & Length of lines, <br /> Total length/size <br /> FILTER BED ❑01�Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I'V'Depth Size _ Number <br /> SUMPS Ll i.� Distance to nearest: Well Foundation ' Property Line <br /> I DISPOSAL PONDS ❑Ili <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 /> i 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 /> i 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." 1` <br /> I The applicant must c I for all req fired inspections. Complete drawing o reverse side. +. <br /> Signed )�A �,' p l K Title: Data: !l <br /> F DEPA TME T USE ONLY <br /> Date Area <br /> Application Accepted by <br /> - <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> I �I <br /> Additional Comments: <br /> � 11 Stk 466-6781 1:1 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 /> r CK RECEIVED BY DATE PERMIT'NO. <br /> .] <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> r EH 13-24 iREV.1/851 �vr O �, �'! -�F ��r� <br /> EH 14-2a <br />