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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT nl,� <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) L� <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. /J <br /> /�Y City Lot Size PM <br /> Job Address <br /> �^ .4 7 7`![�f <br /> hone 7�Z_30) 27 <br /> Owner's Name Address <br /> Contractor's Namesead <br /> License No. s Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll OTHER <br /> ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR 11OTHER ❑ <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 /> Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom 17] Manteca <br /> El Domestic/Private ❑ Type Pack ❑ Tracy of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout S. <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _.V <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION @REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic hitem emitted if public sewer is <br /> available Installation will serve: Residence±�Commercial— Other <br /> Number of living units: / Numberof tedrooms- — l0 J <br /> Character of soil to a depth of 3 feet: ` Water table depth � <br /> SEPTIC TANK Type/Mfg arc-�e44:K Capacity�5-� No. Compartments 2— e <br /> Method of Disposal <br /> PKG. TREATMENT PLT. 1:1 � � i� <br /> Distance to nearest: Well L� Foundation 0Property Line <br /> 3 �� Total length/size <br /> LEACHING LINE B�No. & Length of line <br /> FILTER BED l' Distance to nearest: Well Foundation 30 Property Line <br /> SEEPAGE PITS Depth O^ Size_ Number <br /> ,f,,K�--A� r ` <br /> SUMPS ❑ Distance to nearest: Well L 1�C— Foundation 0 Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cq"t-(-ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> rtify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I ce <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 mW call o a squired inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: ~` Date: <br /> FOR DEPARTMEN USE ONLY <br /> Date Area <br /> Application Accepted by <br /> �� <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date 3� <br /> Additional Comments: <br /> ❑ Stk 4664MI ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copi�s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMENTDUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> + EH 1324 1REV.101831- L S <br /> EH 14-26 `� <br />