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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT S �. <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> II Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED < <br /> (Complete in Triplicate) <br /> Applicaon is hereby ade to the Sn Joaquin n described. This <br /> cation is <br /> madinti <br /> ntrcompliance with San Joaquin County ordinalncle Nto.549 for sewage or h District for a permit <br /> 1862 for we l//pump and the Rules and jRegulationss of the San l Joaquin <br /> Local Health District. !I <br /> Job Address <br /> rr,n City Lot Size PM <br /> i <br /> i I Phone <br /> Owner's Name' Address l!� <br /> M Address Q License No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: N WELL EJ REPLACEMENT LIDESTRUCTION El <br /> PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS <br />° INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> LJ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> ❑ Domesticl Private El Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout - <, <br /> I 1 Irrigation :. Approx. Depth l,! Eastern Surface Seal installed by <br /> Repair Work Done CJ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION ( I DESTRUCTIONAl INailabptic systele thin m feet.)milted 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 ❑ ;Type/Mfg Capacity No. Compartments r <br /> r PKG. TREATMENT PLT. ❑ „ Method of Disposal <br /> } <br /> '!Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ :No. & Length of lines Total length/size <br /> FILTER BED ❑ '� Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS ❑ ' Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 <br /> i rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "l 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 fallowing: "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 ofC -ornia." <br /> The applica m or it o omplete drawing erse side. ., <br /> Signed X <br /> Title: Date: <br /> t FOR DEPARTMENT USE ONLY c <br /> Application Accepted by y Date — 8 ' Area <br /> i Pit or Grout Inspection by 'i date Final Inspection by Date <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 CI Manteca 823-7104 D 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 CK H RECEIVED 9Y DATE PERMIT'NO. <br /> INFO ��11 <br /> *,EH 13-241REV.I/n51 � ! M7(p <br /> EH 14-2$ <br /> W <br />