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V 2 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON 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 /> Job Address City Lot Size PM <br /> Owner's Name �� Address _A-- - <br /> 42 Phone <br /> /017 <br /> Contractor-' Addres License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIROTHER ❑ <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 t <br /> ❑ Industrial - , ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f-I Public C1 Other Ll Delta Depth of Grout Seal Type of Grout <br /> ­_­ <br /> I i Irrigation _..Approx. Depth l Eastern Surface Seal Installed by - <br /> Repair Work Done Type of Pump ' H.P, T�7� State Work Done <br /> 12 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth k Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available 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 /> y .. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well = Foundation Property Line <br /> SEEPAGE PITS I i Depth l Size _ Number I <br /> SUMPS [--I Distance to nearest: Well Foundation Property Line # <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thisrapplication 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.cehifies 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 permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of C ia.'* <br /> The a ant mu call] for all requ' rnspe ns. C plete drawing verse side. <br /> Signed x b- Title: Data: All <br /> f� <br /> FOR DEPARTMtlENt USE ONLY r <br /> _ f,/� <br /> Application Accepted by r Date r t✓ Area <br /> Pit or GroutInspectionbyy :Date _ r; ::F.inal Inspection by Date L /f <br /> Additional Comments: � <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca x-623-7104 ❑ Tracy 635-6365 <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 CK CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO �) <br /> +.EH 13-24 IREV.t i K 51 <br /> EH 14-28 �/•J/ <br />