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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. <br /> Job Address City Lot Size PM e <br /> Owner's Name Address Phone <br /> Contractor's Name License No. L Phone i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ° ` . ,.OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. k PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i Y <br /> 4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel 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 /> Repair Work Done ❑ Type of Pump H.P. State Work Done S- <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth, I Filler Material (Belo ) <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION ❑,� REPAIR/ADDITION DESTRUCTION ❑ Mo septic system permitted if public sewer is <br /> 4 z available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms_--!0 <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. ❑ 1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines I Total length/size in <br /> f <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t j <br /> SEEPAGE PITS 0Depth• Size t Q71' Number ti <br /> SUMPS =stance to nearest: Well fr dation Property Line_ � R <br /> DISPOSAL PONDS ❑ r <br /> I hereby certify that I have prepared,this application and that the work will be done iri accordance with-San Joaquin county ordinances, state laws, 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."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 m t r a quire i s ctions. Completed ing on r e side. �} <br /> 4 Signed Title: Date: <br /> R <br /> FOR DEPARTMENT USE ONLY <br /> x lli <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection.by Date Final Inspection by Date <br /> Additional Comments: — <br /> ❑ Stk 466-6781 4 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE <br /> NFO Ir 'AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ! DATE PERMiT"NO. 5 <br /> + EH;13241REV.10183} �� �¢ /���g� �ty� <br /> SH W28 <br />