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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> j 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 11209) 466-6781 <br /> 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 />` 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 /> 1 Lot Size �� 6C/PM <br /> Job Address City <br /> Owner's Name Addressf�i hone <br /> Contractor's Name License No. .1140!!Z Phone - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES ' DISPOSAL FLD. PROP. LINE` <br /> t. <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 <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 N <br /> Well Destruction ❑ Well Diameter. Sealing Material Itop 501 <br /> Depth s Filler Material iBelow 501 <br /> C TYPE OF SEPTIC WORK: --NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> k t available within 200 feet.) <br /> Installation will serve:Residence-XyCommercial Other <br /> Number of living units: —/— Number of bedrooms <br /> Character of soil to a depth of 3 feet: F Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 7�f�� Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> v Distance to nearest: Well Foundation Property Line +(/c <br /> .LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation_ Property Line <br /> .t <br /> SEEPAGE PITS �Depth ,.�+� Size Number 'i: •- Y <br /> SUMPS ❑ Distance to nearest: Well 4!' Foundation Property Lige f <br /> V <br /> f 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 r <br /> rules and regulations of the San Joaquin Local Health District. ' w �' A .4 <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 w6rkman's compensation,laws of California."ContActor'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 mu II f r ail required 'inspection. Co late drawing on reverse side. <br /> i a <br /> F x Signed Xa _— Title: Date: <br /> FOR'DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> r ` Area r <br /> l <br /> Pit or Grout Inspection by Date Final Inspection by Date r' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623 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 /> r <br /> FEE AMOUNTDUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + H 13-24 MEV.10!831 <br /> .. EH 14-28 <br />