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t <br /> s <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T 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 Sart Joaquin <br /> Local Health District. <br /> Job Address City Lot Size PM <br /> Owner's Name ' °� f Address Phone �� <br /> Contractor Address `��d +�77 <br /> License No. K�honerl6���' <br /> TYPE OF W L/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑'Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RE AIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> ✓, �� '!C available within 200.feet.) <br /> Installation will serve: Re ence_ ommercial_ Other <br /> Number of living unitsNumber of bedrooms <br /> Character of soil to aArthIf 3 feet: Water table depth. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disl <br /> Distance to nearest: -Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/ze � <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Lnj�Oepth Size_4 d i/ Number <br /> SUMPS ❑ Distance to nearest: WellFoundation e_ Pro <br /> perty Line ... <br /> DISPOSAL PONDS ❑ ti <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: "I certify that in the i3�rformance 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 df 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 shall 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 /> Signed X Title: Date: <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ' } -CL ' / <br /> Date ` Area <br /> Pit or Grout Inspection by Date_ Final Inspection by Date <br /> t <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 a❑ 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 /> ' 9 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EH13-24SkEV,ria5l <br /> JF <br /> EH 1428 - <br />