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:w <br /> t APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in'Triplicate) J <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 �1 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 3 1 =¢ . y r <br /> Job Address -7 Ciry Lot Size PM <br /> Owner's Name <br /> Address / `�' _Phone <br /> / 23 3 - . <br /> Contractor's Name �'� Phone-3�� � e Nd•4 <br /> TYPE OF WELL/PUMP: NEW WELL%❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION V SYSTEM REPAIR 1-3 OTHER ❑ J <br /> DISTANCE TO NEAREST: SEPTIC TANK' �' SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` <br /> LlIndustrial ❑,,Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing 1 i <br /> Specifications <br /> C�Domestic/Private ❑ Gravel-Pack' ❑ Tracy Type of Casing � <br /> i <br />'k Public ❑ Other '�� ❑ Delta Depth of Grout Seal <br /> � Type of Groui� <br /> ❑ rou1 I <br /> { Grout- <br /> -'q"' _ _ 1 <br /> ElIrrigation ---Approx. Dept ❑�E�astern ,face Seal Installed by <br /> Repair Work Done, ❑ Type of Pump H.P. State Work Don <br /> l -,Well Destruction O Well DiameterSealing Material {t p 501I" 1 <br /> ` <br /> Depth Filler Material [below 50)t- <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 1-1DtSTRUCTION EIINo septic system permitted if public sewer is <br /> k available within 200 feet.) i <br />} Installation will serve: Residence Commercial_ Other + <br /> Number of living units: Number of bedrooms ` <br /> xi <br /> Character of soil to a depth of 3 feet:` Water table depth <br /> SEPTIC TANK ❑ Typel Mfg Capacity. No. Compartments <br /> PKG. TREATMENT PLT. 71 '� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line1 <br /> ' Total length/size— <br /> LEACHING LINE ❑ No. & Length of linesT , <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> t <br /> DISPOSAL PONDS ❑ <br /> i <br /> I 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, an <br /> r 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 /> a 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 /> t The applicant call or all requir nspections. C mplete drawing ::�erseside. <br /> 1 , �I <br /> f l� Date: <br /> Signed <br /> f <br /> FOR DEPARTMENT USE O�N�LY-41, <br /> Application Accepted by / Date �b Area <br /> Pit or Grout Inspection by Date ,-Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> F + EH 13.24(REV.101831 �—15 O�—l` �`571 <br /> EH 14-28 - <br />