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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 /> City t Size PIN i <br /> Job Address <br /> Owner's Name <br /> - ddress Phone <br /> f �16 <br /> s icense <br /> Contractor 1Vo. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISPOSAL FLD PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Industrial <br /> T of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack racy Type g Type of Grout <br /> El ❑ Other ❑ Delta Depth of Grout Seal t j <br /> ❑ Irrigation prox. Depth ElEastern Surface Seal Installed by <br /> t Repair Work Done Type of Pump <br /> H P State Work Done <br /> L] Well Diameter Sealing Material {top_ <br /> Well De ion ' <br />{ Depth Filler Material (Below X01 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION aveilabPeiwthSne20D feettted if public sewer is <br /> [Atr�� <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms. <br /> I Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 4 <br /> Distance to nearest: Well Foundation - Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> Size Number, 1 ' i <br /> SEEPAGE PITS E3 Depth, _ _ ._ _ <br /> SUMPS O Dista3nce to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance witfi 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 per <br /> is issued, 1 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 /> The applicant st f 1�inpections. o pi 9 drawing verse side. <br /> f <br /> Title Date: <br /> Signed <br /> I i <br /> � FOR DEPARTMENT USE ONLY -7 <br /> Date `� '8j� <br /> 7 Area v <br /> k Application-Accepted by'� ' <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by S� <br /> Additional Comments: <br /> J 'a/ 19-( �� G(l�f rC,1 - 6- 9 --2d <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -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 /> t FEE CK RECEIVED BY DATE PERMIT•NO. <br /> INFO AMOO�UNT DUE AMOUNT REMITTED CASH <br /> + EH 1324iREV.+/B5} ,;gsov e7 �-`�' <br /> EH 14-26 F <br />