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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> `r 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 11 (Complete in Triplicate) <br /> Application is hereby made to the San Joao lin 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 /> { , 1� "7` 1 d'� _-_ Ci ze f PM <br /> Job Address Lot Si <br /> �' <br /> 71 <br /> �V <br /> Owner's Name Address Phone <br /> 411 7 <br /> Contractor's NameV: icense No. � Phone v �� � <br /> �t <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 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON_tTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well,Excravation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type-of Casi =r Specifications <br /> ❑ Public ❑ Other ❑ Delta. _,7'pepth of.Grout Seal, Type of-Grout �� r <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surf c S al'IMall dl by <br /> Repair Work Done ❑ Type of Pump H.P. Q StTe Work Done <br /> Well Destruction ❑ Well Diameter ! I Sealing Material (top 501 . <br /> Depth f Filler Material (Belo } <br /> TYPE OF SEPTIC WORK: NEW INSTALLAT N ❑ REPAIR/ADDITION DESTRUC ION,P (No septic 1!system permitted-if public sewer is <br /> available`wnthin-200°feet.) <br /> Installation will serve: Residence_ Commercial_ Other :- <br /> Number of living units: Number of bedrooins'S� i 1 <br /> Character of soil to a depth of 3 feet: 1 ��`` - Water table depth <br /> SEPTIC TANK C1Type/Mfg -Cap cty ._ No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation- _ Property Line , <br /> LEACHING LINE No. & Length of lines i Tote) length%'size <br /> FILTER BED ❑ Distance to nearest: Well� � Foundation Property Line <br /> SEEPAGE PITS ❑ Depthze Number <br /> ❑ Distance to nearest: Well Foundation Prop1 rty Line_ Q� <br /> fSPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work+mill-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 <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 id issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mot ca r al wiredftnione. Complete yawing on r rse side. <br /> Signed X � ��- Title: Date: <br /> FOR DEPAR MENT USE ONLY <br /> rt o�App' ation Acce d by Date! �` Area <br /> spection by Date 16 `6' ''Final Inspection by ate6Z. Ct <br /> Additional Comments: iT - <br /> ❑ Stk 4664781 ❑ 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 AMOUNT DUE ' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-24 4REV.1019W d & q=�m <br /> EH 14-25 !� <br />