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.1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I J } <br /> 1601 E. HAZELTON AVE., STOCKTON, CA x' <br /> Telephone (209) 466 6781 i t. r <br /> PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED <br /> �. �T <br /> (Complete in Triplicate) rr'f" i 57--R 1:CP1 <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 /> ., f <br /> Jab Address o f (,l,i.J�'-• 5'�_� City Lot size PM t <br /> �� <br /> Owner's Name Address Phone r <br /> a 1 3 License No. Phone " � Z <br /> Contract-. Address t <br /> TYPE OF WELL/PUMP: NEW WELL © a WELL REPLACEMENT L] DESTRUCTION ❑ f <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation• Dia. of Well Casing <br /> *omestic/Private ❑ Gravel Pack_ ❑ Tracy Type of Casing Specifications <br /> t`1-Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout . <br /> I I irrigation -Approxi Depth I i Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Don r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 1 {1 <br /> Depth Filler Material lBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.i REPAIR/ADDITION IA-DESTRUCTION I 1 INo septic system permitted it public sewer is �✓ <br /> I f available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other I <br /> - Number of living units: Number of bedrooms - <br /> Character of soil to a depth of 3 feet: ' Water table depth r <br /> SEPTIC TANK ❑ Type/Mfg Capacity -. No. Compartments . I <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> BLEACHING LINE ❑ No. & Length of lines - Total length/size - ^, <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size - Number. f <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line f <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 i <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 which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must all f r,all required inspections. Complete drawing on reverse side. <br /> Signed - Title: — Dater <br /> DRQ PARTMENT USE ONLY <br /> r <br /> Application Accepted by Date v Area <br /> Pit or Grout Inspection by Date Final Inspection by <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 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +.EH 13-24(REV.i i H al SQ-Iov <br /> EH 14-26 <br />