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u <br /> APPLICATION FOR PERMIT rel <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ADV <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 1984 <br /> Telephone (209) 466-6781 SAN JOA <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NEALrN4'TRoC, <br /> (Complete in Triplicate) CA" <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 `e y 4 City Lot Size PM <br /> I <br /> Owner's Name ,� Address .1U47g��� Phone <br /> Contractor's Name 62 License No. Phone 4, <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 i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> &-150mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t <br /> ❑ Public ❑ Other ? ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. De th Eastern S rface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dong Q <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth I Filler Material (Below 501 nv/� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer <br /> I available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: "I' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg :I Capacity No. Compartments <br /> Disposal <br /> PKG, TREATMENT PLT. ❑ } Method of osal� # P e <br /> Distance to earest: Well Foundation Property Line <br /> ;nI I�•� <br /> LEACHING LINE ❑ No. & Length of lines Total length/siae h i <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 <br /> SEEPAGE PITS ❑ Depth I Size Number <br /> SUMPS ❑ -'Distance to-nearest:­­Well –=- Foundation - - --Property Line - <br /> DISPOSAL PONDS ❑ I t <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, 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 is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mstll required_inspections. Complete drawing on arse 'de. <br /> Signed X,�14. 0 � Title: Date: <br /> ! FOR DEPARTMENT USE ONLY / / # <br /> Application Accepted by Date �` �l Area ®� _ <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> r <br /> Additional Comments: <br /> ❑ Stk 466-67$1 ❑ Lodi 369-36211 ❑ 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 <br /> .i <br /> INFO AMOUNT DUE T. AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT"NO. <br /> l <br /> + EH 13-24[REV.101831 Ll S C'j O q-7 <br /> EH 1426 <br />