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u �» APPLICATION FOR PERMIT / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �5� <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 CIL I <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 /> Job Address } J�$ _ City of Size l ^ PM <br /> Owner's Name ddress T /IL 1 Phone <br /> Contractor Address / L License No � Phone LL !r?� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ff 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 ❑ Gravel Pack ❑ Tracy Type of Casing --l—IX--specifications. <br /> ( � , <br /> 1"1 Public ❑ Other ❑ Delta Depth of Grout'Seal I_-�;jype of Grout _ �U <br /> I I Irrigation _..Approx. Depth I 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 501 f <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 ! DESTRUCTIONINo 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..O Method of Disposal 1 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Lenyth of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> _ le <br /> SEEPAGE PITS I i Depth s Size Number,. �_ I <br /> SUMPS 0 Distance to nearest: Well Found Ion�' �' °P'rape y.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. <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 subcontracting 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 applican,nnust call for all required inspections-Complete•drawing-on reverse side:• -- -^-- - <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE OJ/ 1 Z�Q <br /> Application Accepted by Date ✓[ J t/C�J Area '1 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466 6781 ❑ Lodi 369-3621 KlVantaca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Erivirormental Health Permit/Services WI E. *Hazelton Ave., P.0. Box 1 <br /> 20Q9, Stk., CA.9520 �., <br /> kF'i , mss?'.* <br /> ' INFO �A+M�OUNT FEEDUE AMOUNT EMITTED ~CASH RECEIVED 6Y DATE PERMIT NO. <br /> tEH1 -24IREV.i/nal /� /' 1 <br /> EH 144-28 <br />