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A- <br /> APPLICATION FOR PERMIT <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone {209) 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. 18611 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health'District. r} <br /> Job Address �(' �v /" (J City Lot Size <br /> �,,n{� PM <br /> Owner's Name �� �'' Address `S a Phone ,`r <br /> Contractor �� Address <br /> License No. Phone <br /> 7 WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑' OTHER ❑ <br /> DISTANCE TO NEARES :; TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> P <br /> INTENDED USE TYPE OF WELL P M AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 11i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing , <br /> I i <br /> ❑ Domestic Private i ❑ Gravel Pack ❑ Tracy Type ing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Type of Grout <br /> ❑ Irrigation �Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump AREA <br /> State Work Done O <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT( <br /> �-I'vailable <br /> o septic system permitted if public sewer is <br /> ( 1 within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other LLVJJ <br /> k <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 No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: 'Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size i <br /> FILTER BED ;�' ti ❑ Distance to nearest: .,Well Foundation Property Line R <br /> i <br /> SEEPAGE PIT' ❑ Depth 'Size Number <br /> SUMPS �p ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 of licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 F <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 appli a .k. call for all required inspections. Complete drawing on reverse side. <br /> Signed {i Title: <br /> Dater'- <br /> - F DEPARTMENT USE ONLY <br /> Application Accepted by" ' Data p Area <br /> Pit or Grout 1 Inspection by ' Z111Date Final Inspection by Data z <br /> Additional Co�'I ments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <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 RECEIVED BY DATE PERMIT NO. <br /> + EH14-24(REV.t/95) i "�' S� <br /> EH 5426 � <br />