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�o <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON 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 J � /r .� City Lot Size PM <br />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: "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 whichl this permit is issued, I shall employ persons subject to workman's compensa- <br />tion laws of California." <br />The applicant m cal for all re ' ed inspection Complete drawing on reverse side. <br />Signed ie: Date: <br />FORD PARTMENT USE ONLY �} �� f <br />Application Accepted by - - - .Date - Area <br />Pit or Grout Inspection by bate Final Inspection by " � e�� Date <br />Additional Comments: .0 <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 96201 <br />+ EH 13-24 IREv. 10/83) <br />EH 14-26 <br />FEE <br />INFO <br />AMOUNT DUE AMOUNT REMITTED <br />Owner's NameP,414L_ <br />c <br />DATE <br />Address/ Phone <br />Contractor's Name <br />License No. A-39,3 Phone 36 ~ J }+* <br />TYPE OF WELL/PUMP: <br />NEW WELL. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION 01 SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWEh LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION = AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Industrial <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />ER, Domestic/ Private <br />❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />❑ Public <br />❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br />❑ Irrigation <br />—Approx. Depth ❑ Eastern Surface Seal Installed by <br />—/ <br />Repair Work Done �r Type of Pump, H.P.- %rState Work Done <br />Well Destruction ❑ <br />Well Diameter Sealing Material {top 501 <br />Depth Filler Material (Below 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br />/ available within 200 feet.) <br />s Installation will serve: <br />Residence _ Commercial _ Otherf. <br />Number of living units: <br />Number of bedrooms ° <br />Character of soil to a depth of 3 feet: _ Water table depth <br />SEPTIC TANK <br />❑ Type/Mfg w Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />❑ I Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE <br />❑ No. & Length of lines Total length/size <br />FILTER BED <br />❑ Distance to nearest: Well Foundation Property Line t <br />f <br />SEEPAGE PITS <br />❑ Depth Size Number <br />SUMPS <br />❑ Distance to nearest: Well ` Foundation Property Line <br />DISPOSAL PONDS <br />❑ r i <br />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: "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 whichl this permit is issued, I shall employ persons subject to workman's compensa- <br />tion laws of California." <br />The applicant m cal for all re ' ed inspection Complete drawing on reverse side. <br />Signed ie: Date: <br />FORD PARTMENT USE ONLY �} �� f <br />Application Accepted by - - - .Date - Area <br />Pit or Grout Inspection by bate Final Inspection by " � e�� Date <br />Additional Comments: .0 <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 96201 <br />+ EH 13-24 IREv. 10/83) <br />EH 14-26 <br />FEE <br />INFO <br />AMOUNT DUE AMOUNT REMITTED <br />CASH <br />RECEIVED BY <br />DATE <br />PERMIT LNO. <br />4 4,S <br />° 0 <br />J <br />57 -� �� <br />