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APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 `n <br /> PERMIT EXPIRES EXPIRES 1,YEAR FROM DATE ISSUED U � <br /> (Complete in Triplicate) "'tN <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. 9 r:• `f ' + * <br /> f <br /> Job Address y City, Lot Size PM <br /> Owner's Name <br /> Address d <br /> Phone <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/P P: NEW WELL ❑ WELL.REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ k4N,,k-,SYST.EMAEPAIR':_❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC T SEWER LINES, DISPOSAL FLO. INE <br /> FOUNDATION LTURE WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CTiON SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Exc on Dia. of Well Casing <br /> ❑ Domestic/Private [-]..Gravel Pack racy Type of Casing Specifications <br /> i' ❑ Public �❑ Other b ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface.Seal Installed by <br /> Repair Work Done ype of Pump H.P. State Work Done <br /> Well Destructio . ❑ Well Diameter Sealing Material Itop 50 <br /> r <br /> Depth Filler Material (Below 501 lu <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIOMn iNo septic system permitted if public sewer is <br /> available within 200 feet.) t <br /> Installation will serve: Residence Commercial— Other – 4 P i« 1 <br /> Number of living units: Number of bedrooms <br /> y , <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK >� Type/Mfg Capacity No. Compartments 'w <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line j <br /> a LEACHING LINE ❑ No. & Length of lines Total length/size <br /> r FILTER BED ❑ Distance to nearest: Well Foundation 'Property Line <br /> a <br /> i <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance'to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <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 /> i Home owner or licensed agent's signature certifies-the'following:-"I-ortify 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 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 California." <br /> f _�Ttis-a ant m t call for all required ' ctions. Complete drawing on reverse side. <br /> Signed i Title: Date: <br /> Y <br /> f FOR DEPARTMENT USE ONLY <br /> Application Accepted by �"" Date Area <br /> Pit or Grout Inspactio Date r Final Inspection by Date <br /> 9 Additional Comments: AL <br /> ❑ Stk 466-6781 ❑ Lo 389-3621 VO 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 AMOUNT DUE AMOUNT REMITTED ' CASK RECEIVED BY DATE PERMIT NO. <br /> INFO V <br /> �} <br /> +EH 13-24(REV.t/H51 +��f�� <br /> EH 14-28 �J ✓✓ -� _ <br />