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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA I <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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size <11131 XI PM <br /> Owner's Nam �' 0 Addre Phone <br /> Contracto Address License Phone, G <br /> .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ y* DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'l Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation ____.Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done _ Vt <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filter Material (Below 501 J' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION lNo septic system permitted if public sewer is <br /> available within 200 fetal rn <br /> Installation will serve: Residence_ Commercial_ Other V F <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. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line kI <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER HED ❑ Distance to nearest: Well Foundation Property Line { <br /> I <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS Cl Distance to nearest: Wel! Foundation Property Line I <br /> DISPOSAL PONDS ❑ j <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, I shall not a <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 fallowing: "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 applican u t call r all required i ctions. mplete drawing on reverse sid . <br /> Signed X r -Title: * _ Date: <br /> FOR DEPARTMENT USE ONLYIN <br /> . Q�} <br /> Application Accepted by Date + Area U� <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I <br /> Applicant - Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE "PEIRMITNO,INFO <br /> EH 14'24 1REV.i/Ft 51 <br /> EH 1428 „} �I <br />