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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 TYEAR 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 /> 1 ; /'7D It City�— Lot Size PM <br /> Job Address <br /> Owner's Name <br /> �l1 Address ` ` Phone <br /> Contractor attic.. License No 3� �-- Phone��5 - - � <br /> [-:1-' '`-' '�ddress � <br /> TYPE OF WELL/PUMP: NEW WELL LlWELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELt PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. <br /> Dia. of Well Casing <br /> ❑ Industrial -❑ Open Bottom LJ Manteca Dia. of Well Excavation - <br /> VDomemic/Private D Gravel Pack ElTracy Type of Casing Specifications <br /> FI Public (=1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> --- <br /> I I Irrigation Approx. Depth I 1 Eastern r Surface Seal Installed by - <br /> ��,( f H p. � State Work Done <br /> Repair Work Done Y� Type of Pump - <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 HEPAIRlADDITION l I DESTRUCTION I I (No septic <br /> system <br /> m rented if public sewer is . <br /> Installation will serve: Residence Commercial Other <br /> } <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 /> r Distance to nearest: Well Foundation Property-Line <br /> i f <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines - <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS { I Depth Size Number <br /> SUMPS Li Distance to nearest: Well Foundation ..� Property Line <br /> 4 <br /> DISPOSAL PONDS ❑ ; <br /> that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application 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 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 /> I The applicant must call for all required Complete drawing on reverse side. 1 <br /> Title: Date: �� <br /> Signed . <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by Date Area Q <br /> 4 Pit or Grout inspection by Date Final Inspection by cz Date L 3b- <br /> I Additional Comments: <br /> C1Stk 466-6781 L1 Lodi 369-3621 El Ma 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 /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. <br /> ` INFO <br /> ! +.EH 13-24(REV.I/x 5) — <br /> EH 14-26 <br />