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o-1 <br /> �5 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �n <br /> 1601 E. HAZELTON AVE., STOCKTON, CAD w4. <br /> Telephone {209} 466-6781 Mo <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplete 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 `1 t/ r City S f G /0 A1J Lot Size 75 x S-0 PM <br /> Owner's Name PG=5 C J I C { D2,"'6-1 . Address A)P Phone 4& <br /> Contractor Address License No. Phone_ <br /> IE <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 /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j <br /> �J I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _Approx. Depth ❑ 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 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION {No septic system permitted if public sewer is <br /> .._ available within 200 feet.] <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms C <br /> Character of soil to aepth 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 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line - 1 <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ . Distance to nearest: Well Foundation 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 /> 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 /> 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." I� 'I <br /> The applicant t call for all required inspections. Complete drawing on,re'verse side. <br /> Signed Xs � �✓u G Title: f Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection .y[Date Final Inspectio _ Date <br /> Additional Comments: 7T /�/ rc7� f►/ <br /> ❑ Sfk"'466-67B1 ❑ Lodi 369-3621 ❑ Manteca 823-7104. ❑ Tracy 835-6385 <br /> i <br /> Applicant- Return all copies to: Environmental Health Permit/Services. 601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED C S RECEIVED BY DATE PERMIT'NO. <br /> + EH13-24(REV �Uv `mac" ► 2,r y, r�� �i"l��Ir , <br /> EH 14-28 <br />