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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE,T 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 thef work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. Q <br /> Job Address /� City Lot Size PM <br /> r <br /> Owner's Name Address V/' Phone �• <br /> Contractor J License No. ! I Phone F �Zf &AV'r," ' <br /> TYPE OF WELL/PUMP: NEW WEL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM PAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES { DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL RE W L OTHER WELL PUTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO STRUCTION SPECIFICATIONS <br /> LI Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing ' <br /> ❑ Domestic/Private ❑ Gravel Pack L] Tracy Type of Casing Specifications <br /> ( Public 171 Other Ll Delta epth of Grout Seal Type of Grout _ <br /> I I Irrigation _.-Approx. Depth I I Eastern urface Seal Installed by ' f <br /> Repair Work Done El Type of Pump H.P. `� State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material-)top 50') rJ <br /> � I <br /> Depth Filler Material {Belo ') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.) REPAIR/ADDITION l DESTRUCTION I 1 lNo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will server Residence Commercials 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 U No. Compartments P-4— <br /> ' <br /> PKG. TREATMENT PLT. ❑ a .4 Method of Disposal a! <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Tntal length/size <br /> FILTER BED ❑ Distance to nearest: Well FoundationProperty Line JI-411J <br /> SEEPAGE PITS I I Depth Size umber__ <br /> SUMPS L� Distance to near - Well/0 Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <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�J <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, t 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> Theapplicant m call for all uired i pections.M1Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FO EPARTMENT USE ONLY /� <br /> Application Accepted by C�(T t ":`_ Date l\=�q 7! [7 Area <br /> Pit or Grout Inspection by Date Final Inspection by 1�+7/ Date i t <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 O 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 /> T...FEE— AMOUNT DUE ' AMOUNT REMITTED` "'CK- ""RECEIVED BY <br /> INFO CASH DATE PERMIT NO. <br /> + EH 13-24 fREV.I/R517� tr,� <br /> EH 14-28 ffJJ VV y r <br />