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I <br /> j APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA k <br /> Telephone {209} 466-6781 , <br /> PERMIT EXPIRES 1'YEAR`FROM DATE ISSUED ` :'- <br /> '7- <br /> (Complete <br /> SSUED " :(Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a Per 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,Rples and Regulations of the San Joaquin <br /> Local Health District. ; "`v�� t. .°:,; , <br /> Job Address <br /> . f — City Lot Size PM ... <br /> Owner's Name 'Address <br /> Phone .. <br /> Contractor� � � Z.l.�/ Address t �_. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ License NoAke�2�_-,Phon <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION F1 SYSTEM REPAIR.� OTHER [-1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LiNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL , <br /> P1T5lSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> [Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Casing <br /> Type of Casing Specificaatiolio ns <br /> ❑ Public ❑ Other El Delta Depth of Grout Seal 1` x <br /> ❑ Irrigation Type of Grout <br /> _.—Approx. Dept stern Surface Seal Installed by j <br /> Repair Work Done f [ Type of Pump`I H.P. <br /> Well Destruction ❑ We11.Diameter State Work Done <br /> Sealing Material (top 50'1 i k <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EDREPAIR/ADDITION ❑ DESTRUCTION C1 (No septic system perrhitted if public sewer is '� <br /> Installation will serve: Residence i pCommercial_ Other available within 200 feet.) w <br /> Number of living units: 'Number Iof bedrooms d <br /> Character of soil to a depth of 3 feet: 4p 0 <br /> SEPTIC TANK. ; Water tabie,depih e <br /> ❑ Typg/Mfg, Capaci <br /> PKG, TREATMENT PLT. ❑ ...ty.- °�' �' No.Compartments--�-- <br /> _ {i <br /> �:�,�+ Method of Disposal r <br /> Distance to nearest: Well t �3r Foundationj— ELI <br /> ty Line 1gLEACHING LINE ❑ No. & Length of lines <br /> ize j FILTER BED ❑ Distana to•riearesti% Well `'Foundationy Line ) "�`'SEEPAGE PITS ❑ DepthSize f v x iSUMPS ❑ Distance to nearest: WeII Foundationy Line }DISPOSAL PONDS ❑ ` � � -r 9 � � (: �.' _a . .-2 <br /> I hereby certify that I have prepared this application and that the work will be done in an Joaquin county ofdinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. t <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 g such manner i to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature { <br /> certifies the following: "f certify that in the Performance of the work for which this permit is issued, )shall em to <br /> tion laws of California.,, employ persons subject to workman's compensa- <br /> The applicant mustall all required inspections. Complete draw ng on reverse side. <br /> z <br /> 'Signed Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY } <br /> Application Accepted by 00/ 1—f—fll 11 <br /> 'Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> • <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 y <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009Stk., CA 95201 <br /> FEE AMOUNT DUE {AMOUNT REMITTEDtK <br /> I <br /> INFO' rt H RECEIVED BY DATE PERMIT"NO. , <br /> + EH 13-24(REV.)/8 W <br /> EH W26 7 <br />