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3 <br /> C, <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 an4eg atio s of the San Joaquin <br /> Local Health District. <br /> �,( <br /> Job Address Cit /` <br /> City Lot Size PM <br /> Owner's Name .� s L <br /> Phone <br /> Contractor � l dress Lic <br /> � <br /> ense No: hone <br /> TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F <br /> ❑ Industrial ❑ Open Bottom _1 Manteca. ' Dia. of.Well Excavation Dia. of Well Casing <br /> E) Domestic/Private ❑ Gravel Pack �❑ Tracy * Type of Casing Specifications <br /> I-] Public """" <br /> C7 Other o n Delta Depth of Grout Seal Type of Grout _ f <br /> I 1 Irrigation _ _,Approx. Depth I i Eastern _�.Surfaca.Saal Jnstalled.by - a <br /> Repair Work Done U Type of Pump H.P. _ State Work Done_ <br /> Well Destruction ❑ Well Diameter afing Material (top 50'1 k !t t <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 171 REPAIR/ADDITION ! I DESTRUCTION ( I (No septic system permitted if public sewer is \1 <br /> I available within 200 feet.) <br /> Installation will serve: Residence� ?Gommerciaf— Other <br /> Number of living units: � NumberIof bedrooms <br /> Character of soil to a depth of 3 feet: J Water table depth— <br /> SEPTIC TANK ❑ Type/Mfg " F <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. [7) ! w <br /> Method of Disposal <br /> Distance to nearest: Well 0_ Foundation Property Line r <br /> LEACHING LINE ❑ No. & Length of li <br /> r nes Total length/size <br /> FILTER BED El Distance to neare��st11: Well. _ Foundations Property Line <br /> SEEPAGE PITS I I Depth' _,LLr�r ze r <br /> `--'-�' Number <br /> 0TM__P__S> CI Distance to nearest: Wellf� <br /> SPOSAL PONDS LI ��` � Foundation Property Line _ <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 F <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." s <br /> The applicant In ust call for all requi d spections. Co plete drawing on reverse side. <br /> Signed X Title: <br /> ( Date: <br /> F. DEPARTMENT US ONLY <br /> Application Accepted by ' Date C`7 _ + <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection b <br /> Date'?-7— <br /> Additional Comments: l i // C <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 s <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 <br /> FEE AMOUNT DUEAMOUNT REMITTEDCK <br /> INFO CASH RECEIVED BY DATPERMIT NO. <br /> x <br /> +.EH 1324/REV,r i x 5) <br /> :::���E <br /> EH 14-2r1 <br />