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I! '` <br /> !i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ij Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I� <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 /> �.6�� <br /> Job Address Ey City Lot Size PM <br /> i <br /> .' <br /> Owner's Na Address �c'2fYA Phone <br /> ik <br /> Contractor� � Address .Z � Lice'se No.���-,��a Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> Ij <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. —PROP, LINE <br /> li FOUNDATION AGRICULTURE WELL OTH R-WlFrC__ PITS/SUMPS <br /> j[INTENDED USE TYPE OF WELL PROBLEM AREA CON STR SPECIFICATIONS +� <br /> ❑ I,ndustrial, ❑ Open Bottom ❑ Manteca of Well Excavation 11 Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing Specifications G <br /> F] Public ❑ Other Delta Depth of Grout Seal Type of Grout <br /> ns ` <br /> I I Irrigation _Appr epth I I £astern Surface Seal Installed by �! _ <br /> Repair Work Done ❑ of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter _ Sealing Material (top 50') �M <br /> Depth Filler Material (Below 501 1M <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I'1 REPAIR/ADDITION i I DESTRUCTION iNo septic system permitted if public sewer is <br /> 11 available within 200 feet.I <br /> Installation will serve: Residence— Commercial_ Other I <br /> .s <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. ❑ Method of Disposal + <br /> F <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. fir Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation I Property Line <br /> SEEPAGE PITS I 1 Depth Size. Number <br /> SUMPS Ll 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. 11, <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 m t call for all r u' d inspections. Complete drawing on reverse side. I <br /> il 1_ 2 0 <br /> Signed Title: Date: . <br /> I FO PARTMENT USE ONLY <br /> i <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by i Date <br /> XF <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑L-bdi 3-69-361 . ❑ Manteca 3-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 <br /> qFEE <br /> K 49 <br /> INFO UNT DUE AMOUNT REMITTED C SH RECEIVED BY Il. DATE PERMIT NO. <br /> i 1 ,C)l7 I� <br /> �.EH 13-24(REV.ti N5) <br /> EH 1t-2B i <br /> Ij ' <br />