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i 4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephohe (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 �� ress / 1 <br /> d -;.Phone <br /> Ad <br /> r <br /> Contt � �S <br /> ractor <br /> f Address 1 _ r'-..t License No. Phon <br /> TYPE OF WELL/PUMP: NfW WELL.„❑.,.,... _ .. WELL REPL-AGEMENT G -1 f3ESTRUCTION.❑— <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USETYPE OF WELL j PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial . Open Bottomi Marrteea W-Diarrof-Weil-Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ( Gravel Pack ❑ Tracy Type of Casi}g Specifications l <br /> 71 Public A] Other =� (=1 Delta Depth of Grout Seal Type of Grout <br /> L_Approx:Depth I i Eastern Surface SealElnstalled by <br /> RepairWork Done ❑ f3#ype of Pump H,P. State Work Done <br /> Well Destruction 11 Well DiameterSealing Material (top 5d') <br /> Depth Filler Material (Bel w 50') _ <br /> TYPE OF SEPTIC WORK; NEW tNST.Al.LATJON.1-1—iEPAIR.�-AE)GIT40 ,DESTRUCTION Ill (No septic system permitted if public sewer is <br /> t� available within 200 feet.► O <br /> Installation will servil: Residence_�-_Commercial— Other <br /> 4 F <br /> J r '� <br /> Number oflivingunits: _ _ _-Numberioi�15edrotims <br /> Character of soil to(ja depth of 3,feet ' Water table depth <br /> SEPTIC TANK Y ElType/Mfy-I Capacity No. Compartments --4 kt f i <br /> PKG. TRA'f1UlENTrPLT. ❑ Method of Disposal r - t <br /> t Distance to nearest: Well Foundation' ; Property Line 1 <br /> LEACHINGS��LINE 1l No. �i Length of lines Total length/size <br /> FILTER BEDS ❑ •�� ' ( <br /> �.H t tante to nearest: Well Foundation <br /> Property Line <br /> r <br /> 'S'EEPAGE PITS�' � Dfepth 4 ��-�►t t in ll3 �. Size r Number <br /> SUMPS . L��Distance Eo nearest: Well FoundationProperty Line <br /> DISPOSALPONOS"Ifheraby certify tha�,l h'a+prepared this application and�that the work will be done in accordance with San Joaquin ctrunty ordinances, state laws, <br /> +"rules;and regulat ns of the San Joaquin Local Health Diktrict'. <br /> Home owner otAicensed 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.ljer4on-in such rr annei as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies thy'following: "I certify tftat'iri the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion 7,of California." N <br /> The applicant must call of all r dNin ctions. Complete drawing on reverse side. <br /> f <br /> Signed X� �� Title: Date: _ <br /> ENT USE ONLYy y,-*!S <br /> Aj�ication Accepted by Date ' Area AIT- <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: C' <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 _,� 9 Manteca 8234104,. ❑ Tracy835:6385 <br /> Applicanth Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave P:Q. Box 2009, Stk., CA 95201 <br /> r INFO AMOUNT DUE I AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> I <br /> +.EH13-24NREV.FiH51 <br /> EH 14-2e" <br /> h <br /> ` -1 <br />