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E <br /> r <br /> APPLICATION FOR,PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-5781 <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 Joa uin <br /> Local Health District. z ,. .- �O T F/ R.p <br /> Job Address EY h- City �Sf '"'I"�.Lot Size r PM <br /> Owner's Name "" re cli- Address Phon Z <br /> Contractor's Name _VCGG License No. _ __ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ REPLACEMENT DESTRUCTION ❑ <br /> ;PUMP INSTALLATION SYSTEM REPAIR ❑ 1 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 J <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 'i <br /> ❑ Public ❑ Other ❑ Delta �. Depth of Grout Seal Type of Grout <br /> ❑ lrrigation ---Approx. Depth ❑ Eastern `k� 'Surface Seal Installed by l <br /> Repair Work Done ❑ Type of Pump d'4 H.P. State Work Done �} <br /> Well Destruction ❑ Well Diameter ._ Sealing Material {to"p 501 q <br /> Depth Filler Material {Below 50') � <br /> Q . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is \ p <br /> "--,available within 200 feet.I �Iv <br /> Installation will serve: Residence— Commercial_ Other t <br /> Number of living units: Number of bedrooms n j <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> C <br /> Distance to nearest: Well Foundation Property Line .r ' <br /> LEACHING LINE ❑ No. & Length of lines Total length/size, ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' hf� <br /> SEEPAGE PITS ❑ Depth Size Number 1 1 <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 16 accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. "" a <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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractoes 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." T . <br /> The applicant J s�call <br /> for I req ' inspect' S. Co late drawing on reverse side.4, E <br /> Signed y Title: Date: ? � — <br /> FOR DEP TMENT'USE ONLY 1 <br /> Application Accepted by -t' Date{/�r�_ Area <br /> "Pit or Grout!n'spection by­4—'­ D"ate" —final Inspection by �.� "Date <br /> _ _ <br /> -Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �! <br /> Applicant.- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +EH 1324(REV.10183) <br /> o� 31--5: �r 4- 3 <br /> EH 1428 � <br />