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r <br /> APPLICATION FOR PERMIT <br /> 'r; . - <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,y STOCKTON, CA <br /> J Telephone-(209) 466-6* <br /> PERMIT EXPIRES;9`YEAR FROM DATE 'ISSUED ' <br /> (Complete In Tripllcate)i­ 4 <br /> I Applicatlon is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work harem 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 Ryles and Regulations of the San Joaquin <br /> Local Health District. '` r 1 ' 44 <br /> » , O T�...,; -•_ �, "�+y". <br /> J N <br /> ", City tLot $tie PM <br /> Job Address <br /> Owner's IN ame Address = _-Phone <br /> Contract - Address f _ License No. Phone <br /> F TYPE OF t.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ mat OTHER El <br /> DISTANCE TO NEAREST .iSEPTIC TANK SEWER LINES/ DISPOSAL FLO. PROP. LINE <br /> ` FOUNDATION AGRICULTURE WELL OTHER WELL 1 PITS/SUMPS <br /> INTENDED USE !' ` TYPE.OF WELL -�PROBLEMAREAf CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial - ❑fLO en Bottoms ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private•.. '❑ Gravel Pack ❑ Tracye'" ' - Type of Casing Specifications <br /> I ❑ Public El Other ElDelta Depth of Grout Seal Type of Grout <br /> I, <br /> 1 j `❑ Irrigation _­Approx. Depth LI Eastern Surface Seal Installed by r <br /> State Work Done <br /> 'Repair Work Done (71 Type of„Pump H.P. ; <br /> Sealing Material (top 50'1 <br /> 4�1NeA Destruction ❑ Well Diametert. ;-- - - - <br /> J Depth{ Filler Material (Below 50') # <br /> A TYPE OF SEPTIC WORK: NEW INSTA�LfATION ❑ REPAkR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer,is [� <br /> .�. / available within 200 feet.l <br /> i (;�/ <br /> Installation will serve: TResidence�s 9 Commercial_ Other' f'” j <br /> � . <br /> -Number'of•living units: ' Number of bedrooms <br /> Charalcter of soil to a depth of-3 feet: ' i Water table depth ` <br /> ' 1 <br /> r <br /> SEPTIC TANK ❑�i?ype/Mfg Capacity No. Compartments <br /> PKG. TIiEATMENT•PLT. O Method of Disposal <br /> Distance to nearest: Welk Foundation—" Property L-iff '- <br /> ` 4" ! d Total length/size <br /> ACHWG'LINE No. & Length of lines` <br /> . <*LE, AX l® �t Pro <br /> ti FILTERJ,BED� El '!Distance to nearest: Well Foundation party Line <br /> SEEPAGE PITS Depth "Sire Num <br /> „ ber <br /> f <br /> SUMPS ,�cY;f❑y' Distance to nearest: Well Foundation ? Property Line - <br /> DISPOSAL PONDS ❑ I <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. I _ <br /> Home 6wner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employtany 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." s �. <br /> I The applicant m t all for ail equir spectio s. Complete drawing on reverse side. lik <br /> r Signed X Title::. ` Date: <br /> A . FOR DEP TMENT USE ONLY <br /> Applic tion Accepted by J ( Date <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: " <br /> k ❑ Stk[ 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 El 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 , RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +EH 13-NI(J'. 51 �` s #- �"" �, "' ��Z� S5 —A <br /> EH 1426 <br />