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4 <br /> APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> e 1601 E. HAZELTON AVE., STOCKTON, CA <br /> { Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> (. I {,, <br /> Job Address f/ f L�1'" i City 1,04hr Lot Size PM <br /> Owner's NameAddress Phone <br /> Contractor (i N`�� Address S%f-j - License No. ~"'' Phone Q 6 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r <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 Dia. of Well Casing <br /> r <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Cl Other ❑ 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 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 �h• <br /> Depth Filler Material (Below 501 <br /> TYPE OF-SEPTIC WORK: NEW INST71 - <br /> TION 1.1 REPAIR/ADDITION I I DESTRUCTION iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— ommercial_ Other <br /> Number-of living units: Number of bedrooms 1 <br /> Character of soil to a depth of 3 feet ai Water table depth v <br /> SEPTIC-TANK ❑, Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal — ' <br /> �^ <br /> r Distance-to-nearest: Well 6 Foundation Property.Line <br /> LEACHING LINE ❑' No. & Length of lines Total length/size <br /> FILTER BED ❑r Distance to nearest: Well f Foundatian�, — -- -Rroperty-Line <br /> SEEPAGE OITS i 1' Depth T Size I Number <br />' SUMPS Ll�—f)istance to-nearest:—Welles•-I Foundation Property Liner r <br /> DiSP05AL PONDS ❑ ; <br /> (.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 /> I y rule`s 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 /> ertiploy�any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting 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." i3 <br /> r <br /> The applicant must call for all required inspections. Complete drawing on reverse side. . - <br /> _ <br /> Signed X. ;Title: 0 Eu'' r Date <br /> a FOR DEPARTMENT USE ONLY r <br /> Application Accepted by Date Y Q Area # I <br /> f <br /> Pit or Grout Inspection by n Date Final[Inspection by Date/�-�- <br /> '� <br /> Additional Comments: rea -00-S <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 .. ]-Manteca 823-7104 .❑ Tracy 835-6385 1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f € j <br /> INFO AMOUNT DUE'S AMOUNT <br /> REMITTED CK <br /> �QCASH RECEIVED BY DATE PERMIT' <br /> a.EH 1 -24(REV.t/ts51 �f}� F \ 03 3 LOY <br /> EH 1 <br /> 4-28 ` �! <br /> i..}.-/ <br />