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sl <br /> APPLICATION FOR PERMIT . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZI_L T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> I <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 /> 7 Z � ' <br /> Job Address G a ��� �� City Lot Size PM <br /> Owner's Name Q h Address 2_ 1.trG rbc Phone r <br /> Contractor ,,po Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 /> 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 10 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"1-Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.-Approx. Depth I ) Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. r State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I -DESTRUCTIO 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <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 No. Compartments <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal <br /> Distance to nearest: Well Foundation` Property line <br /> LEACHING LINE ❑ No. & 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 Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 thai 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 C lifornia." f <br /> The applicanr mu call for II require inspections. omelet drawing on reverse side. <br /> J/ <br /> Sig'ne Title: 4 Date: <br /> JJ FOR DEPARTMENT USE ONLY <br /> Application Accepted by CI> Date'4L Area <br /> Pit or Grout Inspection by t Date Final Inspection by i Date <br /> Additional Comments: I i <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 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> 8�3g6 <br /> .AH1 <br /> IpEV.1/H 51 <br /> EH 1426 �` <br />