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k <br />! .� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT + ' 1 <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA w r <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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address61 �3 <br /> ,- City Lot Size PM <br /> n� <br /> a <br /> Owner's NmgPhone <br /> Address G <br /> Contractor Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> -_PUMP_INSTALLXTION-0"`""" '�YSTE-m REPAIR''p— -OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELLPITS/SUMPS <br /> INTENDED USE TYPE OF,WELL PROBLEM AREA RUCTION SPECIFICATIONS a <br /> ❑ Industrial ❑ Open Bottom ❑ M Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> E] Public ❑ Ot � Ll Delta Depth of Grout Seal . Type of Grout <br /> ❑ Irrigation — pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work D ❑ Type of Pump H.P. State Work Done <br /> Well D uction�"❑f "Weil piarneter"`-- Baling MatenTftop 50'}" � <br /> f Depth Filler Material {Below 50'} r t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> r I 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.+ i Water table depth <br /> 1 SEPTIC TANK ❑ T e/Mf Ce s 1 <br /> VP 9 pacity � Na. Compartments <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal <br /> i �-Distance to'near�st:—Welt _ Foundation Property Line i <br /> i <br /> j LEACHING LINE ❑ No. & Length of lines Total length/size i VV <br /> FILTER BED ❑ Distanceto nearest: Well Foundation Property Line ! <br /> A 3 <br /> SEEPAGE PITS ❑ Depth/ Size Number ! <br /> SUMPS ❑ Distance;to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS b <br /> j 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 /> 1 rules and regulations of the San Joaquin Local Health District. II <br /> ! Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit ifi issued, I shall not <br /> employ any person in suc#i manner as toy become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> { certifies the following: """certify that in the performance of the work for which this permit is issued,I shall employ persons subject to wo{kman's compensa- <br /> tion laws of-Califauua?'' <br /> The appEic I st coli for II r fired Ispections. Complete drawing on rev side. <br /> Signed Title: Data: ! <br /> FOR DEPARTMENT USE ONLY I <br /> Application Accepted by Date rea <br /> Pit or Grout Inspection by Date Final Inspection by' pie i <br /> Additional Comments: ! 1V <br /> ❑ Stk 466-6781 ❑ Lodi 3643621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 !' <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> r <br /> INFO AMOUNT DUE' AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. <br /> + EH3324 IREv.1/851 3S v <br /> EH 14-28 <br /> f <br />