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APPLICATION*- CATION FOR PERMIT [,r�._ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i t 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 /> r^ Local Health District 5-75- M <br /> r <br /> Job Address /ID C+tY Lot Size__! y / PM <br /> A-A!r <br /> 11Y <br /> Owner's Name Address 7 b y <br /> Phone <br /> Contractor Address N License No.&50-911� Phone`. <br /> TYPE OF WELL/PUMP: NEW IVVELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTAL TION ❑ STEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT RE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROS AR CONSTRUCTION SPECIFICATIONS <br /> r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ _ Specifications <br /> ❑ Public ❑ Other ❑ Delta De of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. depth ❑ East n Surface al Installed by <br /> Repair Work Done ❑ Type of Pump H.P. PA <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <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�S Other <br /> Number of living units: Number of bedrooms J <br /> Character of soil to a}depth of-3 feet: AWater table depth <br /> SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to.nearest: Well 100 Foundation 2 Property Line <br /> LEACHING LINE C' No. & Length of lines ,q Total length/size 2— <br /> FILTER <br /> FILTER BED ❑ Distance to nearest: Well_!00 J Foundation .;�® Property Line <br /> SEEPAGE PITS Depth Z. Size Number <br /> SUMPS ❑ Distance to nearest: Wel! _ 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 Califomia."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." <br /> _. The applican must call forarequired inspections.;Camplete drawing on reverse side. <br /> Signed Title: Date: —8W4-6 <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> ApplicalignpGe ted by % Date 21 31 Area �J <br /> Pit or`,rout Inspection • Date -� '5,-8 7 Final Inspection by u Date <br /> Additional Comments: � <br /> ❑ Stk 466-6781 ❑ Lodi 369-5(21. ❑ Manteca 823-71 ❑ Tracy 835-63M 9 7 S e <br /> { <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'N0. <br /> + EH 13.24 iREV.1is51 ­7 0, <br /> EH 1426 QO <br />