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4 <br /> APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 [„ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> tt Telephone (209) 466-6781 <br /> i 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. Thisapplication 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.' x <br /> JJ �1 1 <br /> Job Address �rM1yOU U, City �. t Size PM <br /> I � r <br /> Owner's NameAddress Phone <br /> Contractor_ .FUMAddress 9 a 9!Njcense *Ua_._ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPL ENT bESTRUCTION �+ <br /> PUMP INSTALLATION ❑ EM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW NES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION RICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL OBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ 0 r ❑ Delta Depth of Grout Seal Type of Grout <br /> Cl Irrigation �JApprox_Depth�p-EasternSurface 5eal_Insialled by E peg <br /> i s t yy <br /> N7 N-1 <br /> Repair Work Done Type of Pump r H.P. Stateg*Work Done J <br /> Well Destruction ❑ Well Diameter- Sealing Material (top 50') <br /> Depth Filler Material (Below 50') .1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONA 1No septic system permitted if public sewer is f <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: l Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' Water table depth <br /> _. SEPTIC TANK Type/Mfg ( Capacity a No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal ' <br /> Distance to%nearest: Well Foundation Property Line <br /> } I � <br /> LEACHING LINE ❑ No.& Length of lines a Total length/size <br /> FILTER BED ❑1 Distance tolnearest: Well Foundation Property Line <br /> .�_..�-.:.....a�., <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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. <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, IVsNall 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 /> I <br /> The applicant call for all required inspections 7Completwdrawing o everse side <br /> i <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY �< <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 LI Lodi 369-36211-- ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> # l <br /> INFO AMOUNT DUE AMOUNT REMITTED CK411 RECEIVED BY DATE PERMITNO. �. <br /> + EH 13 1/B5) <br /> EH 14-26 <br />