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i <br /> APPLICATION FOR PERMIT =--'+- t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. , <br /> Job Address d141; � City Lot Size PM n <br /> Owner's Name <br /> Address Phone �e 9Z <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL Cq WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION S SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC,TANK. L✓N SEWER LINE - DISPOSAL FLD:� - PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specific; <br /> ped f V Il Casing <br /> XDomestic/Pnvate ❑ Gravel Pack ❑ Tracy Type of Casing' " - Specificafi <br /> Type of � <br /> ❑ Public • ❑ Other ❑ Delta Depth of Grout Seal yp rout <br /> 17 Irrigation 4 , : Brox. Depth El Eastern Surface Seal Installed by i <br /> Repair Work Done ❑ T dt Pu pGeA T11r-va P. X c — State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501O <br /> Depth Filler Material {Be ow 50'} I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ I)ES CT18NN ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence'��Commercial_ Others"• <br /> Number of living units: Number of-bedrooms <br /> Character of soil to a depth of 3 feet: -- ; Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments,- <br /> PKG. <br /> ompartments "r t <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> E SUMPS ❑ Distance to-nearest: Well Foundation � Property.Line - �Y <br /> DISPOSAL PONDS ❑ <br /> ill be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work w <br /> rules and regulations of the San Joaquin Local Health District. <br /> fy that in the performance of the work for which this permit is issued, !shall not <br /> Home owner or licensed agent's signature certifies the following: "I certi <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 /> I certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. Y <br /> Signed X�-s-+� -�r�i� Title:�� +'­�--D'ate: _-,.. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area , <br /> Date Final Inspection by _ Date <br /> Pit or Grout 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, StO CA✓95201 <br /> FEE gMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. r <br /> INFO C 4 <br /> + EH 1324{REV.7/e 51 00 <br /> �'�- ,3. Qt.� O �A <br /> EH 1426 <br />