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w _ APPLICATION FOR PERMIT y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781. <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED" <br /> 7 (Complete in Triplicate) r <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, with San Joaquin Cob hty Ordinance No.549 for sewage or No. 1862 for well PUMP and the Rules and Regulations of the San Joaquin <br /> n <br /> Local Health District.,: {ri:rt <br /> N ` ' City Lot sire M <br /> Job Addresss <br /> Owner's Name <br /> - Address" e - Phone <br /> Contract <br /> G/ior+./� Address V06 � � �"`""`r License No.,�2�Phone,& <br /> I TYPE OF WELL/PUMP: NEW WELL LJ REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 1: OTHER ❑ ,k <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 <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of Casing Specifications i <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 9 <br /> s <br /> El Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> p Irrigation ---Approx. Depth Q Eastern Surface Seal Installed by ° <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done �} <br /> e Well Destruction ElWell Diameter Sealing Material (top 501 14 ' <br /> Depth Filler Material (Beim 501 <br /> .� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ QEPAI /ADDITION DESTRUCTION 13 (No septic system permitted if public sewer is / <br /> available within 200 feet.) <br /> Installation will serve: Residence f Commercial— Other <br /> 4.": Number of living units: Number of drooms <br /> Character of soil to a depth of 3 feet: - -`" <br /> Water table depth � 1 <br /> c - - _-- -No. Compartments <br /> �.SEPTIC TANK ❑ ._TYpeYMfg Capacity <br /> PKG. TREATMENT PLT. Q i j - A ?' Method of Disposal <br /> Distance to nearest: Well Foundation # Property Line <br /> LEACHING LINE L�No. & Length of lines - Total length/size ' <br /> / s <br /> FILTER BED 171 Distance to nearest: Well fC9C� Foundation �B' Property Liner <br /> ' O <br /> SEEPAGE PITS n Depth A2 Size Number f <br /> `" D WP.roperty-Line <br /> SUMPS � Distance to nearest: Well L Foundation.—A <br /> DISPOSAL PONDS ❑ <br />" I hereby certify that I have prepared this application and that the wvork•vrill.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: '9 certify that in the performance of the work for which this permit is issued, I shall not <br /> c. employ any person in such manner as to become subject to,workmanLs compensation laws of California."Contractor's hiring gr 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 campensa- <br /> t ', <br /> tion laws of California." <br /> The applicant m t call for required inspections. Complete drawing on reverse side. (. - <br /> Signed f Title: � Date' <br /> jl FOR DEPARTMENT USE ONLY <br /> t <br /> r . a Date Area f D� <br /> Application Accepted by �.,. <br /> i Final0Inspect <br /> Pit or t Inspection by on ata/" <br /> by. pvt�l l <br /> Ad I conal Com/hents: <br /> [I Stk 466-6761 ❑Lodi 369-3621 Q Manteca 823-7104 El Tracy '835-6385 <br /> Applicant- Returnall copies to: Envir6nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box-2009, Stk., CA 95201 <br /> A r- <br /> i r- <br /> FEE AMOUNT DUE -AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO, <br /> INFO <br /> + EH 13-24IREV.1/851 `+. <br /> ti�7/ S�-4sy <br /> EH 14-28 <br /> I <br /> k - I <br />