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APPLICATION:FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 /> E , <br /> Job Address City of Size M <br /> M r. [,� <br /> Owner's Name r Address - t <br /> Phone <br /> q6qContractor's NameP I <br /> ense No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL.T] WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ _SYSTEMREPAIR 0,,- , 'A OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ``DISPOSALFLD. 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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications! <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation __—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work pone ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 / J <br /> Depth Filler Material {Below <br /> 00 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ailable within 200 feet.).. ` <br /> Installation will serve: Residence— Commercial— Other (-24-4 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments u <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line j <br /> LEACHING LINE ❑ No. & Length of linen i <br /> g t Total length/size <br /> FILTER BED ❑ Distance to nearest: ` ' Well: Foundation Property tine'" { <br /> .. r <br /> SEEPAGE PITS ❑ Depth Size - <br /> Tr <br /> SUMPS Distance to nearest: Well 4 dation Property'Line T ' j0 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordsn' with San Joaquini county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health,District. •� -, � y t <br /> Home owner or licensed agent's signature certifies the'following."'I certify that in thet`performance of the work fdr 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 /> The applicant m st for all require pections. Complete rawing on re se side. <br /> - � " <br /> Signed Title: Date: <br /> 5 <br /> FOR DEPARTMENT USE ONLY°;' <br /> Application Accepted by :D(m 'Date ��! U <br /> Area ,L� <br /> Pit or Grout Inspection by — �—� Date Final Inspection by i Date 3a V--� <br /> ' r <br /> Additional Comments: _ , Aar- <br /> P(SStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 835-6385 r -� <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 RECEIVED BY DATE " <br /> INFO CASH a PERMIT`NO. <br /> +EH 13.24(REV.10/83) a � !4� <br /> EH 1428 Q <br />