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APPLICATION FOR PERMIT <br /> ,�. SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> y Telephone (209) 466-6781 <br /> }�1 PERMIT EXPIRES 1 YEAR 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> c <br /> Job Address � City Lot Size PM <br /> Owner's Narrr tYi Address f Phone r <br /> Contrac Address License No. <br /> TYPE OF WELL/PU P:.__ NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP iNSTALLATION2 Dy. ' , "K,x,�� SYSTEM REPAIRI❑ V„ OTHER ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES -' ' DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WE <br /> OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Ll Manteca Jj' \Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private - ❑ Gravel Pack ❑,Tracy, Type of Casing- Specifications <br /> 1-1 Public f-i Other Ll Delta Depth of Grout 5ealt;­4 k Type of Grout <br /> I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7-- Type of Pump H.P. State Work Done_ 4 <br /> M <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50') <br /> Depth Filler Material (Below 501; - r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (.I •REPAIR/ADDITION 1_1 DESTRUCTION (No 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 <br /> FILTER BED L7 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owneror 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 <br /> employ any person in such manner as to become subject to workman's compensation taws 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 California." ` <br /> r The applicant. call for all required ins ctions. Complete drawing on reverse side. f <br /> Si ned, l� <br /> 9 Title: __ Date: <br /> .FOR DEPARTMENT USE ONLY f <br /> Application Accepted by Date J 2 Area J • i <br /> Pit or Grout Inspection b { Date Final Inspection by L Date <br /> Additional Comments: NO Prr^-l-iC IN o" <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 /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNTFgR/E�aMITTED CAS RECEIVED BY DATE PERMIT'NO. <br /> +-EH 13-24(REV..1/R 51 00 '35"0/sa { [V.� <br /> EH 14-29 `,� <br />