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y , <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 823' <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA [ .11 C <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES.I-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 /> ` Lot Size PM <br /> Job Address Cityc� <br /> Owner's Name <br /> Address g` -" Phone <br /> � ti License N Phone <br /> Contractor's Name I' <br /> TYPE OF WELL/PUMP: NEW WELL ELL�PLACEMENT ❑ DESTRUCTION ❑ <br /> f PUMP 1NSTALL4TIONfs tS IYSTEM REPAIR ❑ OTHER ❑ JF <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> TYPE <br /> INTENDED USE l TYPE OF WELL'' IPROSLEMAREA: CONSTRUCTION SPECIFICATIONS <br /> 13 Industrial �. ` -E] Open-Bottom --m[]-Manteca = Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of CasingSpecifications i <br /> 9-6omestic/Priva <br /> Private C�"C,oval Pack ❑ Tracy <br /> 17Public -'❑ Other ❑ Delta l& Depth of Grout Seal Type of Grout <br /> ❑ Irrigation <br /> pProx,De th O Eastern., Surf ce,Sea1 Installed by S ! <br /> .► .i <br /> Repair Work Done' ❑ Type of Pump H.P. y State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material IBelow 501 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT ION ❑ availabpe1w'rthsn 200 feetitted if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> Ca aci No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> j Capacity_ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ' I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED E3 Distance to nearest Well Foundation Property Line <br /> -Number <br /> SEEPAGE PITS 13 Depth, Size F <br /> SUMPS ❑ Distance to nearest: Well Foundation' Y Property Line- <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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> rtify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I ce <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." It <br /> f The applicant must call for ell required inspect' s. Complete drawing on reverse side. <br /> iTitle: 1'~"'P�� Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by ��15 � Date <br /> Additional Comments: L <br /> ❑ Stk 466 6781 ❑ Lodi 369-3621 Manteca 82:3-7104 ❑ Tracy 83x6385 �� pfr[iy��S <br /> Applicant- Return all copies to: Environmental eal Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 / O <br /> ' RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO Z3 <br /> + Eli 13-24 IREV.101931 -L716 <br /> (f g�6$3 1J� <br /> EH 14-29 ... - <br />