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,i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT L v <br /> rf. 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> i (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 /> f / 7Y <br /> �x PM <br /> Job Address (../ / City Lot Size_ a <br /> ` Owner's Name Zegft ®\' , /N Address Phone <br /> '\ Contractor " . Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ 'WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Ll SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> :a <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca D.iY.of,Well Excavation Dia.-df Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy --Type of Casing p Specifications <br /> 171 Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout _ <br /> :I 1 Irrigation _Approx.l-Depth t 1 Eastern Surface Seal Installed by. <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done ar <br /> { Well Destruction ❑ Well Diameter Sealing Material (top 501 Chi <br /> Depth Filler Material lBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION l:I DESTRUCTIONINo septic sysfein'permitted it public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other y <br /> Number of living units: Number of bedrooms y <br /> Character of soil to a depth of 3 feet:f Water table depth r <br /> SEPTIC TANK ❑ -Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> � LEACHING LINE ❑ Na..& Length of lines Total length/size <br /> FILTER BED ❑ Distance itbrnearest: Well Foundation Property Line <br /> �s <br /> SEEPAGE PITS I 1 Depth 1 Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I I <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,JoaquiLocal 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 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 applicants must call for all requoq inspection Complete drawing on reverse side. <br /> Title:igned .._.___.. F <br /> r(� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted \04by U1C�Z Dat Area <br /> t - <br /> Pit or Grout Inspection by Date ¢ Final Inspection by Da <br /> Additional Comments: <br /> CK <br /> 5 9 ®�-73 <br /> ❑ Stkv466-6781 Q Lodi - 1 ffManteca 823-710d ❑ Tracy 835- <br /> Applicani- 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 RECEIVED BY OATS PERMIT NO. <br /> INFO ASH <br /> ai <br /> r EH1 <br /> 3-24(REV.1 i n 5) u� <br /> EH 14-20 <br />