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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN 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. 3 <br /> Job Address � 4 City ! Lot Size PM f <br /> 1 <br /> Owner's Name Address Phone <br /> Contract 46 CB Address !'o "760 License No. 3 25F Z 761 Phone <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT El DESTRUCTION ❑ i I <br /> PUMP INSTALLATION',❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDAT Q {' AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ti <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._D,epih ❑ Eastern Surface Seal Installed by ) <br /> Repair Work Done ❑ Type of_Pump H.P. State Work Done J <br /> Well Destruction El Well Diimeter Sealing Material {top 50'1 <br /> Depth. )ler Material (Below 50'1 "' J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR114 <br /> DDITION RK DESTRUCTION ❑ (No septic system permitted if public sewer is OQ <br /> f available within 200 feet.) rf <br /> Installation will serve: Residencek�. Commercial 2Other <br /> Number of living units: Number of bed oms 3 r <br /> Charactet.ofrsoil fo a depth o f,3'feet: t t ! Water table depth <br /> SEPTIC-TANK-, '0' Type/Mfg 9 Capacity;rt-xNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE At-`No. & Length of lines - Q Total length/size <br /> I <br /> FILTER BED Distance to nearest: Well <br /> El Foundation' Property Line:� <br /> a <br /> SEEPAGE PITS Depth Size Number *' <br /> SUMPS ❑ Distance to nearest: Well-0 Foundation--l-ti r Property Line._ <br /> DISPOSAL PONDS ❑ - <br /> 1 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. f^ <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 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 applican ust call f II uired inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> Date: Q <br /> �/ <br /> FOR DEPARTMENT USE ONLY r <br /> Application Accepted by h Date Area <br /> Pit or Grout Inspection by Je 1 Daten Final Inspection by Date� 1 <br /> Additional Comments: <br /> ❑ Stk 466-6781, ,- ❑ Lodi '369-3621 ❑ Manteca 823-7104 ❑ Tracy 83540% <br /> Applicant- Return all copies to: Environmental Health permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;,Stk., CA 95201 <br /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 111 RECEIVED BY DATE PERMIT NO. <br /> i <br /> + EH 13c24lREV.1/as1 <br /> EH 14-28 oQ o <br />