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3 ql,b <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1, EHAZE;'iQN AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br />!` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 4 �� . <br /> Job Address City ze PM <br /> Owner's Name Address /�� + ' •PE'1 bll�iiMer9 ` Phone <br /> Contractor wAddress License IVa. hone <br /> TYPE OF WELL/PUMP: W 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. \ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other jElDelta Depth of Grout Seal Type of Grout <br /> ElIrrigation �__4pproli. :eA❑ stern StUfacp Seal Installed by <br /> t I <br /> Repair Work Done Type of Pump H.P. t"" State Work Done <br /> kWell Destruction ❑..� Well Diameter Sealing Material (top 50') <br /> Depth- a "� ''`Fille'r Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public sewer is <br /> r ' available within 200 feet.l <br /> Installation will serve: Residence Commercial Other <br /> t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fee': Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ } <br /> r Method of Disposal � <br /> Distanceto nearest: Well Foundation _ Property Line <br /> ( <br /> LEACHING LINE El No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation r Property LineIN <br /> .. <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line t <br /> DISPOSAL PONDS ❑ i i <br /> a 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 re a San Joaquin Local Health District. <br /> Home ow r or licensed a nt's signature certifies the following: "I certify tha the performance of the-work for which this permit is issued, I shall not <br /> employ ny person in such anner as to'tiecome subject to work s: <br /> nation laws of California."-Contractor's hiring or sub-contracting signature <br /> certifi the following: "I c i at in the,.perform c the rk r " h this per is issued,I shall employ persons subject to workman's compensa- <br /> tion ws of Cafiforni _ - <br /> �. <br /> The applica mu If all requir gins win on re r ii a. ' <br /> Signe it Date: / A�' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date i`maI7 Area <br /> t <br /> f Pit or Grout Inspection y y Date Final Inspection by Date <br /> I , <br /> Additional Comments: <br /> s ❑ 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. Box 2009, Stk., CA 95201 <br /> FEE o INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMMNO. <br /> l + EH13-24(REV.r/a5) <br /> EH 1428 : 4c.7 0 <br />