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APPLICATION FOR PERMITr! <br /> • �' <br /> = SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> J� Telephone (209) 466-6781 <br /> 111 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. h <br /> t 1� City ;��Lot Size PM <br /> rJobAddress ame _ <br /> �� _ "" Address _ •�(o �� A I �C Phone <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL,FW--,/ PROP. LINE <br /> } FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS <br /> l INTENDED USE TYPE OF WELL PROBLEM ARE NS RUCTION SPECIFICATIONS <br /> EEE ❑ Open Bottom ❑ M� ~j~ Dia. of Well Excavation Dia. of Well Casing <br /> l <br /> El Industrial <br /> Type of Casing Specifications <br /> (D Domestic/Private ;Depth <br /> Gravel Pack racy yP g <br /> Type of Grout <br /> I'1 Public Other ❑ Delta Depth of Grout Seal YP <br /> I 1 Irrigation _..Appr . Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ pe Pump H.P. <br /> State Work Done_ <br /> Well Destruction ❑ ell Diameter Sealing Material (top 50'1 <br /> Filler Material (Below 501 Vim' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION E I. DESTRUCTION 11 availabpelwhhin 200 feetsystemitled it public sewer is <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 <br /> No. Compartments y <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line------- <br /> r <br /> r LEACHING LINE Cl No. & Length of lines- Total length/size <br /> FILTER BED ED - <br /> Distance to nearest: Well FoundationProperty Line <br /> SEEPAGE PITS 1 1 Depth Size Numbir <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line \ <br /> Ij DISPOSAL PONDS C7 \ <br /> [ ccordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work will be done in a <br /> f 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 shat! 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 Calif r <br /> f The applican ust ca for required ' pec ns. le ra mg on reverse side. ! f <br /> Signed X <br /> it e:C Date: <br /> Xk <br /> FOR DEPARTMENT USE ONLY <br /> -f, ` 2 <br /> Application Accepted by !"f �•-�' .Date � Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Q 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, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24{REV.ti 651 <br /> 3S� f - /� <br /> EH 14.28 <br />