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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r ' <br /> € 1601 E. HAZE T ON AVE., STOCKTON, CA �` <br /> T-t 115 Telephone (209) 466-67$1 t <br /> !� PERMIT EXPIRES 1 YEAR FRO&4,DAT.E 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 San Joaquin <br /> Local Health District. <br /> Job Address City 4't Size <br /> Owner's Name s �e t]� r '� <br /> ' ��_ ('hone- • 4- <br /> t' Contractor's Name No. Phone41 4� - r <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ff;_� SYSTEM REPAIR ❑ OTHER.❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK -&e9_[V.&EWER LiNES DISPOSAL FL.D. PROP. LINE <br /> t. FOUNDATION ,1 AGRICULTUREWELLOTHER WELL 01TS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ' <br /> Ll Industrial fpen ttom�BoEJ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mastic/Private EJGravel Pack 12Tracy Type of Casing_ -- Specifications <br /> { ❑ Public ❑ Other ❑ Delta Depth of Grout Seal r`D Ty of-Grout 2 <br /> ❑ Irrigation �4pprox. Depth Ea ern 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 /> I i Depth Filler Material (Below 50') <br /> S .-` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ! available within 200 feet.) <br /> Installation will serve: Residence' Commercial_ Other ° <br /> tNumber of living units: Number of bedrooms rk <br /> } Character of soil to a depth of 3 feet: <br /> Water table depth_ Y <br /> SEPTIC TANK ❑ T e/Mf <br /> I YP g Capacity No. CompartmeMi- <br /> PKG. TREATMENT PLT, ❑ -r + <br /> Method of Dispasl" <br /> Distance to nearest:"":..'Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> ilk <br /> { "Ill/ FILTER BED ❑ Distance to nearest:' Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> t 7•s, <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ +' <br /> herebV 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 /> s ?�v 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."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 all forpjl required inspections. Complete Ing on reverse side. / <br /> r <br /> � <br /> Signed T ®` <br /> i itle: Date: ' <br /> $ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by t Date Area <br /> Pit or Grout Inspection by Date Final Inspection by I <br /> Date r�a <br /> Additional Comments: <br /> 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> ApplicaInt- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE r –gMpUNT DUE'S ""AMOUNT"REMITTED" CK �:_-- <br /> iNFO CASH —RECEIVED BY „M r DATE_- P�FiMIT''NO.:... <br /> + EH 13.24(REV.10/83) �S d0 � <br /> EH 14-26 ,. l <br />