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APPLICATION FOR PERMIT Apt- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.�HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781f <br /> PERMIT EXPIRES'l YE' V0 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 /> Job Address O / rr t; r N 4 1 <br /> 1 w City Lot Size PM <br /> Owner's Name`' <br /> rAddress <br /> y � Phone 6 <br /> Contractor F , ddress ! S <br /> License No.�Phone_ r <br /> TYPE OF 1NELL/PUMP: NEW WELL Q -"-- <br /> WELL REPLACEMENT L-1DESTRUCTION ❑ ,w � <br /> A PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 <br /> DISTANCE'' SEWER LINES TO NEAREST: SEPTIC TANK OTHER L1DISPOSAL FLp. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ _Open Bottom ❑ Manteca Dia.,of Well Excavation E <br /> Cl Domestic/Private El Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> ❑ Public Type of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> Ll Irrigation Type of Grout { <br /> Approx. DepthLl tern Surface seal Installed by <br /> Repair Work Done ❑ Type of Pump H p <br /> State Work Done_ <br /> Well Destruction ❑ Well Diameter _ Sealing Material /top 50'1 <br /> Depth <br /> Filler Material (Below 50'1 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑. REPAIR/AD TION DESTRU DN (No stem Septic system Y permitted if public sewer'.is <br /> t ava4ale within 200 feet.) Q <br /> ii <br /> Installation will serve: Residence Commercial_ Other ti f i c ! <br /> Number of living units: Number of bedrooms ^� ay~ ' 1 <br /> Character;of soil to a depth of 3 feet: f <br /> Wateble depth <br /> SEPTIC TANK w ❑ Type/Mfg 1 <br /> Capacity i No-.Compartments <br /> PKG.'TRrEATMENT PLT. ❑ <br /> Method of Disposal p �, <br /> Distance to nearest: Well <br /> ...�.�___.->_ _Foundation„ ..-_�_ Property Line <br /> LEACHING'LINE ❑' No. Length of lines <br /> Total length/size <br /> FiLTER BED ❑ Distanceta nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS ❑ Depth`s i r Size ` <br /> SUMPS Number <br /> ❑'. Djstance..to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <br /> I hereby certify that i have prepared this application and that the work will-be,. d6ne in accordance with San Joaquin county ordinances, state la s, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the followin r-+ <br /> em to an 9 "I certify that in the performance of the work fp;which-(his permit is•iSSued, I shat not <br /> employ y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring lir sub-contracting signature <br /> certifies the following:"1 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 required inspections. Complete drawing on reverse side. <br /> Signah X r <br /> Title: <br /> Date: <br /> DEPARTMENT USE ONLY ,...t <br /> Application Accepted by Date / <br /> Area <br /> Pit or Grout Inspection by i Date Final Inspectionby O <br /> Date <br /> Additional Comments: J t> - , <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 /> i <br /> }' FEE 1 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PER N <br /> CASH r <br /> r EH 13-241REV.1/85J i <br />