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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA �- <br /> Telephone 120 U�G��� <br /> PERMIT EXPIRES 'Y YEAR FROM DATE 1 UED <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 _:Cy �/S� City la' Lot Size PM <br /> xOwner's Name Address ` Phone P <br /> Contractor Address r License No. Phone eJ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS m <br /> * Industrial ElOpen Bottom EJManteca Dia. of Well Excavation ! Dia- of Well Casing <br /> r <br /> * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'l Public ❑ Other C1 Delta i Depth of Grout Seal Type of Grout <br /> I Irrigation _Approx. Depth I 1 Eastern Surface Seal installed by (� <br /> Repair Work Done 11Type of Pump H.P. State Work Done `? <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') f —_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION €1 REPAIR/ADDITION I I DESTRUCTIO I No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— ,Other _ �� T <br /> Number of living units: Number of bedrooms <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 /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: V e Y Foundation Property Line <br /> i <br /> SEEPAGE PITS I 1 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 laJan <br /> rules and regulations of the San Joaquin Local Health bi"strict. <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 applicant m t;1�'r all required inspection Complete drawing on reverse side._ <br /> Signed X Title: 0,yy) o r Date: ld A 7-9 � <br /> ORUMPARTMENT USE ONLY 'y <br /> Application Accepted by – I Iva Date d o"�3 Area <br /> Pit or Grout Inspection by Date Final Inspection by�� Date /l/3 <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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> IN C H <br /> +.fH1 <br /> 3-24IREV.1/a5l t <br /> EH 14.26 71 <br /> {�7 �/ <br />