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/p <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ! <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> i 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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �I <br /> Job Address !!/ Cit Lot Size PM <br /> AJ <br /> ref <br /> Owner's Name `^� f Address Phone <br /> H Address SQ L icense No. � �U� P <br /> Contractor hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER 1-1 <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE M <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ­0 Ind'ustrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private L� Gravel Pack E] Tracy Type of Casing Specifications <br /> FI Public ❑ Other f] Delta -Depth of Grout Seal. Typo of Grout <br /> 11 Irrit�ation _"Approx. Depth l I 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 501 <br /> Depth Filler Material (Below 50'1 — <br /> TYPE�OF SEPTIC WORK: NEW INSTALLATION AIR/ADDITION l I DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> II Ir 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 ElType/Mi fV <br /> opacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i / Method of Disposal. <br /> Distance to nearest: Well Foundation Property Line_..._?r / <br /> LEACHING LINE ❑ No. & Length of lines:' t _70- <br /> --�/'� �7T�ottalrlength/size <br /> FILTER BED )stance to � <br /> nearest: Well. �u� s <br /> Foundation_�[.� Property Line <br /> SEEPAGE PITS 11 Depth i.—Size Number <br /> '- SUMPS "L�l Distance to nearest: r Well Foundation Property Line <br /> DISPOSAL PONDS ❑ " <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 /> rulesjaind regulations of the'San Joaquin Local"Health District. f ., <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 /> ifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa <br /> tion Ia f Californi #, <br /> The applican It 11 for II re ed in ecti ns Comple flawing on verse sid <br /> jSigna `.Title: Date: <br /> FOR DEPARTMENT USE ONLY r <br /> Application Accepted by Date 47 Area <br /> I Pit o Grout Inspection by Date a�- �F, ection try" Date <br /> Additional Comments: <br /> t ❑ S k466-6781 ❑ 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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH Y RE EIVED BY DATE PERMIT ND. <br /> INFO �]] <br /> + EH 13-24 IREV.t i h 51 V „o?11U <br /> EH 1426 <br /> i h <br />