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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT # <br /> 1601 E. HAZELTON 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. r �, T _ t <br /> Q' � <br /> Job Address f'-- C' Size <br /> Owner's Name ddress a Phone <br /> Ilk <br /> --Contractor'sName �_ _ _ ✓<� o ���� �� �- --, Phone <br /> TYPE OF WELL/PUMP: NEW WELL, 77 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i <br /> PUMP INSTALLATI N'®� d. SYSTEM REPAIR ❑ OTHER ❑ - T <br /> DISTANCE TO NEAREST: SEPTIC TANK C3Ir �' EWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — s� <br /> __. <br /> { INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �nJ-❑'Indu�'strial ,,,pen Bottom"� ❑_Mante-�. Dia. of Well Excavation Dia. of Well Casing <br /> &- is/Priv 1-6 —❑'Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑"Public ❑ Other ,4 El Delta Depth of Grout Seal' -G Type of Gr <br /> kRe <br /> i],irrigation �4pprox. Depth,/V tem Surface Seal Installed bye Espair Work Done ❑ Type-of'Pump` 1i.P. State Work Done '' S <br /> Well Destruction ❑ fwOrDi t r ' C 5/;5-a Sealing Material Itop 501 .l <br /> i_Depth-_ a20y C_& Filler Material IBelow 501 t Ip_ <br /> "\ available within 200 feet.) <br /> TYPE OF SEPTIC WORK:' NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <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 ElType/Mfg Capacity No. Compartments 0 <br /> t" . <br /> �PKG. TREATMENT PLT. ❑ Method of Disposal i <br /> Distance to nearest: Well Foundation Property Line q <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance-to-nearest:­—Well-_=----Foundation---- Property Line <br /> SEEPAGE PITS ❑ Depth Size Number r <br /> SUMPS # ❑ Distance to nearest: Well Foundation 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 county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I <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."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 call all required inspections. Complete on reverse side. [� <br /> Signed -_—�s� �g__� Title: Date: `J <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Date ! Area <br /> E <br /> Pit Grout spection by Date Final Inspection by Date �4 '� <br /> Additional Comments: <br /> ■ Stk466i7i1 Lodi 3W3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 111 <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 w RECEIVED BY DATE PERMIT"N0. <br /> INFO C H <br /> + 6 <br /> EH 324[REV.'1092s:_7tV <br /> EH 4-26 ...,._ <br /> l ` <br /> i <br />