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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> ' Telephone 12091 466-6781 ' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) _ <br /> i 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 /> I 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 J `�r!City Lot Size PM <br /> T� y <br /> Owner's Name �����–/+ f_172", ess Phone <br /> it 109 !� <br /> Contractor's Name .License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION)10fF <br /> �TEM REPAIR ❑ OTHER ❑ 1 <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE QV <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS J� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> WDomestic/Private t rzravel 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 /> t Repair Work Done Ll Type of Pump H.P. �-- State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material IBeIow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> available within 200 feet.I <br /> + Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> l <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 6 SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 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. f r� <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perform`ance,ofYhe 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_"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 ]-shall employ persons subject to workman's compensa- <br /> tion laws of California." ; F <br /> The applicant r requir ions. Complete drawing on r rs ide. <br /> t <br /> Signed Title:, Date• / <br /> FOR DEPARTMENT`USE ONLY— y <br /> Application Accepted by Date "~ Area <br /> Pit or Grout Inspection Date Firial Inspection by,. Date <br /> -- Additional-Comments: — - - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 /> h FEEAMOUNT DUE AMOUNT REMITTED �K RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> + EK 13-24 IREV.10/831 <br /> �, :_�EH 1426 <br />