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1 <br /> 1 <br /> APPLICATION FOR PERMIT <br /> . ­ J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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. 1662 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. r� f �j <br /> Job Address -3 �-+ � �u - City <br /> '/ �/�V- Lot Size PM <br /> Owner's Name A Address Phone E31 - 5-lL1 i <br /> ContractorIAS ,/S4 tM � � _Address �� License No. Phone G-9Ga <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 <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 <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> ❑ Industrial 1-1Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> ❑ Domestic/Private El Gravel Pack 13 Tracy Type of Casing Specifications <br /> 1-1 Public F1 Other H Delta Depth of Grout Seal Type of Grout <br /> l I Irrigation —.Approx. Depth i I Eastern Surface Seal Installed by - <br /> I <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> I <br /> Depth Filler Material (Below 501 <br /> ,TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ; DESTRUCTION I I (No septic system permitted if public-sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence X CommercialOther <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK �V Type/Mfg ��� Capacity�/ No. Compartments 21 + <br /> PKG. TREATMENT PLT. OMethod of Disposal i <br /> Distance to nearest: Well Foundation 0l Property Line <br /> LEACHING LINE No. & Length of lines D Total length/size- ZF <br /> FILTER BED ❑ Distance to nearest: Well MoD Foundation SLS Property Line <br /> i <br /> SEEPAGE PITS 11 Depth Size Number i <br /> SUMPS Cl 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." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> i <br /> FOR DEPARTMENT USE ONLY / � <br /> Application Accepted by Date +� � � Arear�P� <br /> Inspection b Date Final Inspection by �r ate Sq <br /> Pit or Grout pec y <br /> Additional Comments: <br /> ❑ 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 85201 �[ <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE "P5RMIT'NO.INFO CASH <br /> EH 13-24 IREV.t i n s1 <br /> EH 14-28 <br />