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l <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {200} 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. ;I <br /> Job Address !9eA7/�� JIG" City Lot Size_ � / _-_ PM <br /> Owner's Name Address Phone <br /> Contractor Address License No." hon <br /> X_ <br /> TYPE OF WELL PUMP: NEWWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER W PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO IFiCATIONS - <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack} ❑ Tracy ype of Casing Specifications <br /> ❑ Public ❑ Other ❑ Del Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth astern Surface Seal Installed by I <br /> Repair Work Done ❑ Type of Pump -�'` H:P:, - _ State Work Done <br /> Well Destruction ❑ Well Di er . ? .�Sealing'Material (top 50') <br /> Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADDITION_❑k DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other pQ <br /> Number of living units: Number�of bedrooms E <br /> Character of soil to a depth of 3 feet: 42Wa#er table depth <br /> SEPTIC TANKType/Mfg Capacity )No. Compartments Zr <br /> PKG. TREATMENT PL ❑ Method of Disposal �} <br /> 4 <br /> Distance td nearest: (Nell 1_ Foundations`. - Property Line <br /> LEACHING LINE ❑ No. & Length of lines 1 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well _Foundation. Property Line <br /> r <br /> SEEPAGE PITS ❑ Depth §ize Number <br /> SUMPS ❑ Distance to.nearest:,-,, Well Foundation. Property Line��"' ; <br /> DISPOSAL PONDS ❑ � t r ti <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San'Joaquiri county ordinances, state laws, and <br /> rules and regulations of the-San-Joaquin Local'Healfh District. '"'�"""""` ­­ -'"- '1` i_ <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.t&,workman's compensation law_ s of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the perFoimance ofJhawork forwhich this permit is,issued;,l shall employ persons subject to workman's compensa- <br /> tion laws of li rnia." ' ` <br /> The applican 4st cal all.r uir inspections. Com late drawing on reverse side-_ .,,,,b„ <br /> /12 <br /> Signed Title: Date: <br /> l FOR DEPARTMENT USE ONLY s <br /> 1 r <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by +I Date Final Inspection by Dati <br /> Additional Comments: P U t S 4 <br /> -❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ 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 F <br /> t 3 <br /> FEE <br /> !rr <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT`NO. <br /> CASR <br /> a EH 13'14- Q 24(REV.. e 51 � <br /> EH 14-28 ��� �0 � .1.j <br />