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I <br /> i <br /> APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ' PERMIT EXPIRES 9 YEAR FROM DATE ISSU12D <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 /> l 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 /> i <br /> Job Address j :Address/ <br /> City Lot Size tOwner's Nam Phonegg <br /> f �/ <br /> Conttac r Address License N4ZZ�Phon <br /> TYPE OF WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 71 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 O.fF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack LJTracy Type of Casing Specifications <br /> t l'1 Public Cl Other s 171 Delta Depth of Grout Seal Type of Grout — <br /> 4 <br /> i I I Irrigation --Approx. Depth i I Eastern Surface Seal Installed by - <br /> Repaif Work Done EI Type of Pump H.P. State Work Done <br /> Well Destruction' ❑ Well Diameter Sealing Material {top 501 <br /> --Depth-_- Material-{Below I� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 T EPAIR! DDITION I DESTRUCTION l 1 (No septic system per if public sewer is <br /> I available within 200 feet.) <br /> k Installation will serve: Res dance Commercial_ Qlher / <br /> Number of living units: Number f bedr ms �J <br /> Character of soii to a dept f 3 feel: Water table depth <br /> - C�� Ca acR No. Compartments f <br /> SEPTIC TANK ype/Mfg P Y <br /> PKG. TREATMENT F. ❑ f f Method of Disp9sal +` r <br /> l , Distance to nearest: Well Foundation ..__._— Property Line <br /> LEACHING LINE No. 81+ength of lines ' r Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> f' Property Line __:— <br /> SEEPAGE PITS,, Depth! Size ". Number'°•. <br /> c > + � <br /> SUMPS ❑ Distance to nearest: Weil;, Foundation��f -{Property Line <br /> DISPOSAL PONDS ❑ ;# <br /> I hereby certify that I have prepared this application and that the work will 6s dare in accofdarlce with'San Joaquin county ordinances, stateJw. .nd <br /> rules and-regulations of the San Joaquin Local Health District. "`�� �,t <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 perm t isissued,`I shall employ persons subject to workman's compensa- <br /> tion laws of California." y <br /> l � <br /> The applicant m t tail for al quire inspections. Complete drawing on reverse std <br /> Signed X Title: <br /> FORD PARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> oPit r Grout Inspection by Dete Final Inspection by Date fH D <br /> I <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. Bax 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> I ° <br /> i.EH 13-24 1REV.t/H SY O .-� <br /> EH 14-29 .s / 1 <br />