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r <br /> R jr <br /> 3� ~ <br /> APPLICATION FOR PERMIT ~� <br /> 41 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 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 /> 1 <br /> Job Address a __...,._,_ �� — City2l`'a '� Lot Size PM <br /> Owner's N� - J7 Address J 5 -�0 1ST& �- Phone Sz <br /> ContractorAddress License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 \A <br /> © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n1 ~ <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Fl Public 171 Other f i pelta Depth of Grout Seal Type of Grout­-­ <br /> I <br /> rout __.I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction C] Well Diameter Sealing Material (top 50') <br /> Depth Filler Material f8elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIONI No septic system permitted if public sewer is <br /> �� available within 200 feet.► <br /> Installation will serve: Residence y Commercial_ Other <br /> Number of living units: ._._._, Number of bedrooms_:2 <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. ❑ 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 Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Di1trict. <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 applic t must call for all required inspections. Complete drawing on reverse side. <br /> Signed C <br /> Title: L1 Date: Jt� 3 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ���" Area <br /> Pit or Grout Inspection by Date Final Inspection bye. Date <br /> Additional Comments: �l J�.3 r <br /> ElStk 466-6781 13 Lodi 369-3621 CI Manteca 823-7 ❑ Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,'P.0 ox 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PEERMI7'NO. <br /> ♦ EH13-241REV.tirt a) 3S. <br /> EH 14-28 L <br /> �l <br />