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0 -21 <br /> { Z,� APPLICATION FOR PERMIT <br /> 1 ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 743 6 <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 1 <br /> r I <br /> Job Address Fm City Lot Size `�+ rJ eG PM <br /> Owner's Name f! Address _ ��, 4 / Phone 3- 0 <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER "F <br /> s <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 /> rr <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 ii Or e Fl Delta Depth of Grout Seal Type of Grout <br /> I t Irrigationpprox, Depth l I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> a <br /> Depth f Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITION l I DESTRUCTION I I {No septic system permitted if public sewer is <br /> % available within 200 feet.) <br /> In tallation will serve: Residence_ Commercial— Other <br /> Numbe wing units: Number of bedrooms <br /> Character of soil t th of 3 feet: Water table depth <br /> SEPTIC TANK _ ❑_ y 4 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑� �. Method of Disposal <br /> e to nearest: f Foundation Property Line <br /> LEAC LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well FoundationProperty Lines <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 t <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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all requi ed ectionje Complete drawing on reverse side. <br /> Signed X Title: 42&IA?� Date: <br /> r <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by _ Date `G 0 Area 2 <br /> /�� <br /> Pit or Grout Inspection by Date Final Inspection by Date/ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 D Tracy 835-63$5 <br /> i <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 RECEIVED BY DATE PERMi7'NO. <br /> +,EH 13-24 1REV.r/H s1 <br /> 3 *3 of S&J A_a&74 <br /> EH 14-26 <br />