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F 0 n <br /> APPLICATION FOR PERMIT <br /> F. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I 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 /> # i 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 /> i y Local Health District. <br /> Job Address - _� '�__` - __I_`-` __ _ I \" Cityof Size PM <br /> �J-e 4 "d. QJ 10 2 <br /> Owner's Name // r' � !" A�dress � Phone <br /> Contractor's Name icense No. Phone��� <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> F <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications g <br /> w ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout N <br /> i <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by lel <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done V} <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 Uti <br /> Depth Filler Material f Below 501 d <br /> FTYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitt if public sewer is <br /> available within 200 feet./ i <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 /> SEPTIC TANK [�­Type/Mfg Capacity ,(ND. Compartments e2-- T <br /> r PKG. TREATMENT PLT. © Method of Disposal <br /> [ DistarlcQ is nearest: <br /> Wei Foundation _ Property Line O <br /> 666` <br /> LEACHING LINE 0---No. & Length of lines - "- " Total length/size- <br /> FILTER BED 2r-__Distance to nearest: Well, Foundation' La Property Line <br /> SEEPAGE PITS z` Depth S~� Size Number - <br /> SUMPS ❑ " Distance to nearest: Welt,Lr'� t Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> ` 1 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."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 applicant ust call for Ire sired inspection Complete drawing on reverse side. <br /> R 1 Signed Title: A- Date: L 0 " <br /> A /. <br /> FO DEPARTMENT USE ONL <br /> Application Accepted by Date Area <br /> r Grout Inspection by ���� ate s 'Final Inspection by Date <br /> Piss <br /> Additional Comments: <br /> F, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE` INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMITNO. <br /> + EH 13.241REV.101831 1 <br /> EH 14-26 -"-L<. t1%C=F <br />