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4 <br /> f � ! <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIIN LOCAL HEALTH DISTRICT <br /> I <br /> 1 1 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> a✓�^tP QPG�c Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i. <br /> I,I iccimplete 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 flor sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> ' B City Lot Size PM <br /> Job Address <br /> I <br /> Owner's Name D w' Address Phone <br /> Contractor �G ✓� �d Address C —�+�License No Phone l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR �r 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 /> 1-1Industrial 11Open Bottom j❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack n ❑ Tracy I Type of Casing Specifications <br /> 1-1 Public Cl.Other f❑ Delta Depth of Grout Seal Type of Grout <br /> --- <br /> I I irrigation -Approx. Depth w I I Eastern Suri a Seal Installed by - <br /> Repair Work Done ;5 Type of Pump -5�- H.P', t - State Work Done G <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> —Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIRI,ADDITION i I DESTRUCTION ! I (No septic system permitted if-public sewer is <br /> I available within 200 feet.) <br /> I it <br /> Installation will serve: Residence CommercialOther <br /> Number of living units: Number of bedrooms i <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. ❑`;' t Method of Disposal <br /> ',":Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑:: No. & Length.of lines •� ` Total length/size <br /> FILTER BED "."Distance to nearest: Well �_ Foundation, <br /> ❑ Property Line <br /> SEEPAGE PITS I-I Depth t` Size Number <br /> " SUMPS L1Distance to nearest: Well i Foundation } Property Line <br /> DISPOSAL PONDS e. r <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 /> t 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 applic t call for all required ctio Co ete drawing on arse side. <br /> s <br /> Signed X Title: lP Date:. <br /> FOR'DEPARTMENT USE ONLY <br /> 10 Application Accepted by _ i Date Area <br /> i <br /> Pit or Grout Inspection by, Date 'I Final Inspection by Dat ._-.__ <br /> Additional Comments: <br /> Ll Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +13.24 1REV.i H 5} •�� p 1 U 1"-1�� <br /> //g <br /> 28 <br />