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Ar <br /> APPL1CATION�FOR PERMIT ., <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON,AVE., STOCKTON, CA f <br /> Telephone(209) 466-6781 f� <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED N+lu <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 welllpump and the Rules and Regulations of the San Joaquin { <br /> Local Health District. / <br /> City tat Size PM <br /> Job Address <br /> � Phone <br /> Owner's Name Address X" <br /> Address <br /> 6 License Pho U <br /> I Contractor <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL•REPLACEMENT ❑ DESTRUCTION ❑ <br /> r PUMP INSTALLATION E3SYSTEM REPAIR ❑ OTHER t <br /> SEWER LINES DISPOSAL F PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK ER WECI_ PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom -- [I Ma e - - Dia...of Well.,Excayation-. - <br /> Tracy Type of Casing Specifications <br /> L, DomesticlPrivate ❑ Gravel Pack Type of Grout <br /> (� Other ❑ Delta Depth of Grout Seal <br /> [7 Public f <br /> I I Irrigation .. pprox. Depth I I Eastern Surface Seal Installed by <br /> Type of Pump H.P. State Work Done <br /> Repair Work Dona YP , ' x <br /> l Well Destru n ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material,lBelow,50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1, DESTRUCTIO aNailabpelwithin Z00 feetit�ed if public sewer is <br /> Installation will serve: Residence, Commercial— Other t <br /> „__' <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of'soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK (11Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT- ❑ <br /> j Distance to nearest: Well Foundation Property Line <br /> t r - Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> i <br /> FILTER BED Li Distance to nearest: 'Well Fpundation Property Line <br /> j <br /> SEEPAGE PITS l I Depth iSize Number, <br /> SUMPS ❑ Distance to nearest: Well - Foundation T Property Line <br /> I DISPOSAL PONDS ❑ ' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin;coun y ordinances, state laws, and <br /> rules and regulations of the-Sah Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work forwhich 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: "1 certify that in the perfofmance 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 applica ust call for all required inspections. Complete drawing on rave side: <br /> { Date- <br /> Sign <br /> ate: <br /> Signed 5 Title: <br /> j F PARTMENT USE ONLY n1 t <br /> Date— <br /> Application Accepted by <br /> r... k Date. Final inspection by Rate <br /> � Pit or Grout Inspection by <br /> Additional Comments: ti ra <br /> r ❑ Stk 466-6781 ❑ Lodi 369-3621 EJ Manteca 823-7104 ❑ Tracy 835-6385 q:_ <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O- Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> t INFO AMOUNT DUE AMOUNT REMITTED H <br /> + EF113-24(REV.t/H51 <br /> EH t4-26 <br />