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r. <br /> A' <br /> APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 , <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete-in Triplicate) I' <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 welt/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> L 4 <br /> Job Address .City Lot Size PM <br /> XOwner's Name Address �i � �J .ftone <br /> ddress License Na Phone. <br /> Contractor s <br /> TYPE OF WELL/PUMP:.. ` e: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ . OTHER ❑ (1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE V <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " <br /> LT Industrial ❑ Open Bottum ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing <br /> ❑ Domestic/Private '❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ; ❑ Other f ❑ Delta Depth of Grout Seal Type of-Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by + <br /> I <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Qepth Filler Material (Below 501 F <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No:reptic system permitted if public sewer is <br /> 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 tablefdepth <br /> SEPTIC.TANK , -0 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 [IDistance,to nearest: Well Foundation a Property Line ; <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance,to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ `.a <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 /> Home owner or licensed agents 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 semploy persons subject to workman's Compensa- <br /> tion laws of California." <br /> The applicant must call for required inspections.,Complete drawing on reverse side. ry <br /> '9. � ofs. — Date: <br /> X Signed Title:. lcZl <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> D to OCC�`ti 1 <br /> Application Accepted by Y <br /> -�.� �- . � Dateoff <br /> Pit or Grout Inspection b Date Final Ins tion by <br /> Additional Comments: j�i[/7/ .i �� ��r. <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 8x1-7104 ❑ Tracy <br /> Applicant - Return all copies to: Environmental Aealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 , <br /> 7" <br /> FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> r <br /> + EN 13-24 IREV.5/a 51 - 3 �^ i S 07 <br /> EH 1426 �J <br />