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� 3 <br /> i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED MAY <br /> (Complete in Triplicate) [ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thele' I application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the ZONE he San Joaquin <br /> Local Health District. <br /> C <br /> Job Address E ity IL Lot Size PM <br /> C S,� � dK e Phone <br /> Owner's Nam ]Address <br /> Contracto G Address+ G' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR je' 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> J Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout---.—. <br /> f I Irrigation —.App(ox, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0< Type of Pump k, H.P. I State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I I Mo septic 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: 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 i <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size _ Number <br /> SUMPS 0 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 i <br /> 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 0 <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 compens (} <br /> tion laws of California." `xf1)•o <br /> The applic t call for all requir nspect' s. Co plate drawing on r e side. <br /> Signed X G Title: p���; Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date( Area <br /> Pit or Grout Inspection by Data Final Inspection by l / Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.riH5) O� <br /> EH 14.211 — I �1 t7 t� <br />