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E:_9 w 4 <br /> APPLICATION FOR PERMIT _. <br /> V <br /> SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEI`TON 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 /> C2 <br /> Job Address _157 L/� ��51'� - Cit Lot Size PM <br /> 4 <br /> C L <br /> Owner's Nam r — Address Phone `* <br /> Contractor L Address License No. Phone } <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ C -SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK_ rSEWER-LINES--- — DISPOSAL-FLD.- PROLINE �. <br /> ___ _ FOUNDATION AGRICULTURE WELL OTHER WELL PIT-9/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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �1J' <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern —Surface Seal Installed by <br /> Repair Work Dane ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 jp <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is Oma <br /> I t NTilable within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms - « <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ . Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines _ _ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation = Property Line <br /> SEEPAGE PITS ❑ Depth Size Number y <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line { <br /> DISPOSAL PONDS ❑ <br /> 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 regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: ' certify that in the performance of the work for which this permit is issue"d, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. ¢� <br /> SignedX .-:� Title: Date: <br /> —IOU <br /> L1/! FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 anteca 823-71 ❑ 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 AMOUNT DUE AMOUNT REMITTED As RECEIVED BY DATE. PERMIYNO. <br /> INFO L 7 <br /> r, + EH13-24(REV.t/H5) � �0 �•� ��/`� 7 <br /> EH 1428 /// <br />