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1 � <br /> r _ _ <br /> I APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZET-ON•'AVE., STOCKTON, CA <br /> Telephone(2'09) 4i6-6781 <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. rl <br /> Job Address /&:/. Ci t Size PM <br /> Owner's Name Address ® C)M Phone <br /> Contract 1+1 res, License No. Phone <br /> TYPE OF WELL/PUMP: . NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION'] _ ! , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ tt ! <br /> DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINES , f f. <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 —A <br /> , <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r <br /> r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> El Irrigation ---Approx. Depth 171Eastern"" F Surface Seal-Installed by A! !fr Y <br /> Repair Work Done_O T _e of Pump H.P. "St tae 1�Vork Don, <br /> —Well Destruction WelhDiamete� Sealing Material )tap 50') C '-*_AA <br /> Depth �-B Filler Material (Below 501 <br /> o.# <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-❑u-REPAIRIADDITION [A—DESTRUCTION ❑ (No septic system permitted if public sewer is x.. <br /> available within 200 feet.) <br /> Installation will se esid'ence Commercial_ Other .- <br /> Number of living units: 1, r r of bedrooms <br /> Character of soil to a depth of 3 feet: � '' Water table depth <br /> SEPTIC TANK 'O'.Type/Mfg ` Capacity ' No. Compartments <br /> PKG. TREATMENT PLT. E] 1 f' Method fDisposal <br /> IDistance to nearest: Well <br /> �FoundaProperty Line <br /> �l # <br /> LEACHING LINE 0. .No. & Length of lines '" ""Total length/size <br /> FILTER BED ❑- `Distance to nearest, Well Foundation Property Line _ <br /> SEEPAGE PITS C7,.Depth ( Size Number <br /> SUMPS •❑ Distanceto nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ' 1 <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> rules and regulations of the Sari Joaquin Local Health District. e <br /> Home owner d 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 a person in suc lanner as to'be ome subject arkman's comperisation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies a following:"I ce ify that in the o anc f e work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion la of California." _ ._.� <br /> The a licant mu all r re t om ng on rev s' <br /> Signed Title: Date: <br /> I <br /> FOR DEPARTMENT USE ONLY01. <br /> ,y <br /> Application Accepted by DRa �� Area ,v <br /> IE <br /> Pit or Grout Inspection by Date mal Inspecfian byDate 9 <br /> Additional Comments: f a if �7 G�o�feC� yip� <br /> ❑ Stk 466-6781 ❑ Lodi 369421 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 4b <br /> .f <br /> FEE <br /> CK <br /> I <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> + EH 13-24(REV.t/B5) $ CP co ,;' <br /> EH 1428 <br />