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I " <br />} <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. <br /> Job Address 3,2053 <br /> ) City Lot Size PM <br /> Owner's Name W Address Phone <br /> Contractork5ess 1(J a V <br /> rLicense No.' 4277 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION ❑ O <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 /> I ❑ industrial Elpen 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 rface Seal Installed by <br /> Repair Work Done ❑ Type of Pum Zei L <br /> Yp P II ' H. zl State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 y <br /> Depth I an � _ Filter Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet-1 <br /> Insta a server Residence— Commercial__�_ Other <br /> Number of living units. Number of bedrooms <br /> Character of soil to a depth of 3 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ d� Method of Disposal <br /> Distance to nearest: Well dation Property Line <br /> LEACHING LINE ❑'- No. & Len th of lines ` <br /> 9 To th/size <br /> FILTER BED * . ❑: Distance to nearest: Well foundation Prop ine <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: -Well Foundation ,Property Line <br /> DISPOSAL PONDS ❑ <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, an <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 Calif rnia." <br /> The applicant st call r all re inspectiorA. Complete drawing on reverse side. <br /> Signed Title:' Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date S`'t45- <br /> 0 <br /> rea a <br /> Pit or Grout Inspection by Date Final Inspectign by Date <br /> Additional Comments: �Stk 466-6781 ❑ Lodi, -3621 ❑ Manteca 823 7104 ❑ Tracy 6385 { <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Bo 2x�, Stk., CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE EPERMIT6NO.♦ EH 14-2d[FEV.I/n 51 ����EH 1428 L.� <br /> I <br />