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co <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.;:STOCKTON, CA <br /> Telephone (209) 466-6781 � _ t <br /> fr=-X <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> k(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 l <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 <br /> Local Health District. n Joaquin <br /> i <br /> Job Address .. "' ' . <br /> a&12.4— <br /> _ City Lot Sizee <br /> - PM + <br /> Owner's Name Address <br /> j Phone f0 <br /> Contractor 1 Address 0 �� `e y <br /> License No. Phone 6 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LiNES <br /> DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE A TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> 19 Domestic/Private ' Dia. of Well Casing w- <br /> �. ❑ Gravel Pack. ❑ Tracy Type of Casing <br /> ❑ Public ❑ Other Specifications <br /> ❑ Delta depth of Grout Seal <br /> ,❑ IrrigationType of Grout <br /> Jq <br /> pprox. Depth ❑ Eastern Surface Seal installed by <br /> Repair Work Done Type of PumpT u H P rl I� .l <br /> State Work Done # <br /> Well Destruction ❑ ' Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: ResidenceCommercial Other available within.200,feet.) <br /> — � i . . <br /> Number of living units:; Number of bedrooms aid <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> © Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ <br /> Method of Disposal <br /> n <br /> Distance to nearest: Well Foundation Property Line <br /> 1i � <br /> rLEACHING LINEf r Y <br /> ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well l <br /> l Foundation Property Line <br /> SEEPAGE PITS ❑ Depth 1 Size k F <br /> SUMPSNumber: t <br /> ❑ Distance to nearest: Wall 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 /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signaturecertifies the following: "!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 theperformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." f , <br /> The applicant must call or all required inspections. Complete drawing on reverse side. <br /> 9 r <br /> Signed X Title: � <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by pate <br /> _ 19— Areaq <br /> Pit or Grout Inspection by Date Final Inspection by ate "�` <br /> Additional Comments: ` <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 95201 t <br /> FEE AMOUNT DUE AMOUNT REMITTED CK j <br /> INFO CASH RECEIVED BY DATEE �y PERMIrT_NO. <br /> + E 13-24(REV. <br /> tiies7 S`CSC3 fes- f !`�l�P � <br /> EHH 1478 <br />