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a '~ <br /> a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'wt <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> �� City Lot Size PM <br /> Job Address '-3 <br /> E Address Phone <br /> Owner's Name <br /> �r I moi+ 1 <br /> Contractor Add -400 7 �/�+ < �Eicense No.'SY>�4 Phone <br /> I <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 CONSTRUCTION SPECIFICATIONS a I <br /> C1Industrial ❑ Open Bottom 11Manteca IDia. of Well Excavation Dia. of Well Casing <br /> r Type of Casing Specifications <br /> Domestic/Private El Gravel Pack' ❑ Tracy YP 9 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth� ,,E�!!Eastern Surface Seal Installed by <br /> Repair Work Done LlType of Pump.. f H,P. State Vyork Done <br /> Well Destruction . ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material.IBelow 501 j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION"❑ IDESTRUCTION ❑ INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other A # <br /> Number of living units: -i Number of bedrooms r <br /> Character of soil to a depthyof 3-feet: Water table depth t . <br /> SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments <br /> PKG. TREATMENT PLT. ❑ "'Method of Disposal <br /> f Distance to nearest: Well Foundation Z. Property Line LA <br /> � m <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Wel! Foundation Property Lineg <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wil�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,1 shall employ persons subject to workman's comperisa- <br /> tion laws of California." <br /> The applicant m st call f required inspections. Complete drawing on rev rse side. <br />' Signed w Title: Date: <br /> k . <br /> FOR DEPARTMENT USE ONLY p c� <br /> I � Ar <br /> AP <br /> Application Accepted by �✓" Date <br /> Pit or Grout Inspection by Date Final Inspection by <br /> rft <br /> Additional Comments: <br /> l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 873-7104 ❑ Tracy 835-6385 <br /> 1 Applicant- Return all copies to: Environmentai'Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2p, Stk.;XW%5201 X 0 <br /> l FEEAMOUNT DUE AMOUNT REMITTED K RECEIVED BY DAT ERMIT"I <br /> INFO CASH <br /> / <br /> + EH 13-24(REV. <br /> _ EH 14-28 <br />