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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA L� <br /> Telephone (209) 466-6781 <br /> I� PERMIT EXPIRES TYEAR 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 weil/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. I) . <br /> E jrtCf" City idG r_JLot Size� x a PM f <br /> Job Address / L <br /> �` Lj� 1 Address T �`' _ I rJ Phone��� <br /> r �(. Owner's Name _ :J <br /> r` rll <br /> _, �-� " <br /> Address License No. Phone <br /> Contractor <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 FED.— PROP:LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1Dia. of Well Casing ` <br /> 11Industrial ❑' EJ Bottom Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> Ll Domestic/Private E),Gravel Pack F1 Tracy S <br /> Cl Other f i Delta Depth of Grout Seal Type of Grout <br /> (-1 Public _ <br /> { I I Irrigation '1 -Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of,Pump H.P. State Work Done_ <br /> !wdif <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Fi11er Material {Below 50'}TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION 1 1 DESTRUCTION (Nailsepticable systeithin 206 feetllic sewer isInstallation will serve: Residence�.— Commercial— Other <br /> Number of living units: �I. Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ I Type/Mfg Capacity No. CompartmentPKG. TREATMENT PLT. ❑il Method of Dispos'-. <br /> Distance to nearest: Well Foundation Property Line <br /> I! <br /> r <br /> LEACHING LINE ❑ No- & Length of lines Total length/size <br /> FILTER BED ❑' Distance to nearest: Well Foundation Property Ine <br /> i <br /> SEEPAGE PITS l I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: IWell 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 District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work far which this permit is issued, I shall not <br /> employ any person in such manner as to became subject to workman's compensation laws of California." Contractor s hiring of 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." II } <br /> f The applicant must cal r'all required inspections. Complete drawing on reverse side. ' <br /> Signed X Title: Date: <br /> >�`1�1�iT Q�e� <br /> FOR DEPARTMENT USE ONLY Q q <br /> O Area 1 <br /> Application Accepted by Date <br /> i. <br /> Pit or Grout Inspection by 1i1 Date Final Inspection by Date <br /> Additional Comments: <br /> ElStk 466-6781. ❑!Lodi 369-3621 C3 Manteca, 823-7104 ❑ Tracy 835-5385 <br /> Applicant -.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> • li• <br /> y FEE AMOUNT DUE AMOUNT REMITTED C H RECEIVED BY DATE PERMIT"NO. <br /> +.EH 1324 IREV-1./H 5Y <br /> EH 14-26 <br />