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AL <br /> 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 /> f 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 3 �/ a - <br /> - Ci s/Lot Size PM <br /> r Owner's Name Address 7 <br /> Phone <br /> Contractor Address <br /> ttt License No. Phone <br /> TYPE OF WELL/PUMP—NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ fndustrW 15 Open Bottom ❑ Manteca Dia. of Well Excavation <br /> 7-1Domestic/Private C3Gravel Pack ❑ Trac Dia. of Well Casing <br /> _ Y Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Sea! <br /> ❑ Irrigation _A Type of Grout <br /> F pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. y� <br /> State Work Done <br /> r <br /> Well Destruction ❑ Well Diameter Sealing Materia! (top 50') <br /> Depth Filler Material (Below 50'1 <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial_ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ T Water table depth <br /> ype/Mfg <br /> PKG. TREATMENT PLT. ElCapacity No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> a <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED El Distance <br /> length/size <br /> Distance to nearest: Well Foundation � <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ED - Property Line <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 i <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 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 must call for all required inspections. Complete drawing on reverse side. _ <br /> Signed <br /> Title:A4 <br /> _ Date: (p <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date lz <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by , <br /> Additional Comments: �Date. <br /> ❑ Stk 466-6781 ❑ Lodi 369 1 ❑ Manteca 823-7104 ❑ Tracy t <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 <br /> INFO RECEIVED BY �`DATE PERMIT NO. <br /> + EH M24 fREV.)/95) O� 4r, <br /> �J/ <br /> , ■ I "f V T\._V,� .. <br /> EH 14-28 ti 1 <br />