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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 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 /> Job Address 7 City &�/kLot Size PM <br /> r/l <br /> Owner's Name Address � Phone <br /> Contractor's Address License Phone v <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> l`l Public 171 Other ❑ Delta Depth of Grout Seal <br /> ° Type of Grout <br /> I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. . State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> _ r <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRlADDITION l I DESTRUCTINX INo septic system permitted if public sewer is <br /> available within 200 feet-) <br /> Installation will serve: Residence Commercial— Other R <br /> Number of living units: Numher of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth'' �- x <br /> SEPTIC TANK ❑ Type/Mfg 3 Capacity 'No. Compartments <br /> i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation w Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS I 1 Depth Size # Number <br /> SUMPS ❑ Distance to nearest: Well lFoundafion I 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 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 subcontracting 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 /> I 1 <br /> i The applican us al! f ail required ins t ns. Complete drawing on reverse side. _ <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by .Date re <br /> 03 <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by044 0 2ANLL Date <br /> Additional Comments: <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> A plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDC SH RECEIVED BY DATE PERMIT"NO. <br /> INFO `� C { (r, <br /> ♦ EH 13-24 IHEV.t i w 57 J� �.J I. ®� ""'9 0 <br /> EH 11-28 <br />