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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 /> E Application is hereby made to the San Joaquin Local Health'D'ietrict for a permit to construct and/or install the work h8rein described. This,application is <br /> i made in compliance with San Joaquin County Ordinance No.'549 for sewage or No. 1862 for veil/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. !i <br /> Job Address c/ Z �_ ,�� �' City" PV Lot Size <br /> PM <br /> Owner's Name `� �ry Address" w �� <br /> Phone <br /> 'i <br /> Contractor Address License No. '' Phone <br /> TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT i]. 'DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ `a OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPDSAL FLD. OP.�LIN%--�FOUNDATIONAGRICULTURE WELL OTH PITS/S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic!Private ❑ Gravel Pack ❑ Type of Casing Specifications <br /> f'] Public �F]�Other (1 Delta Depth of Grout Seal t Type of Grout _ <br /> I Irrigation ox. Depth I 1 Eastern Surface Seal Installadby <br /> Repair WorkDpump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material_(top 501 . <br /> Depth Filler Material (6elow'50') <br />! TYPE OF SEPTIC WORK: NEW INSTALLATION I:) REPAIR/ADDITION I "D£STRUCTIO INo septic stem r (� <br /> A Y permitted if public sewer is U' <br /> f available within 200 feet.) <br /> Installation will serve: 'Residence,_ Commercial_ Other n <br /> Number of living units: Number of bedrooms <br /> Character of sil.to a depth of 3 feet: Water table depth <br /> SEPTIC TANK.. ❑ Type/Mfg Capacity" No. Compartments <br /> PKG. TREATMENT PLT. ❑ 3. .1 Method of Disposal <br /> Distahce to nearest: Well ; <br /> Foundation Property Line <br /> LEACHING EINE ❑ No. & Length of lines "` <br /> f f 6tal,lengtrh/size <br /> FILTER BED ❑ Distance to nearest: ' Well Foundation 'Property Line <br /> 1 I � � <br /> SEEPAGE PITS I I Depth Size r <br /> Number <br /> SUMPS Cl Distance to nearest: Well Foundation I ` <br /> I <br /> Property Line <br /> DISPOSAL PONDS ❑ i <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with $an.Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. II <br /> Home owner or licensed agent's signature certifies the followin <br /> am <br /> ploy an g: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> p y person in such manner as to become subject to workman's compensation laws of California."Contncctor'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, <br /> tion laws of California." I shall employ persons subject to workman's compensa <br /> The applicant),Aust call for all re ired ins -` - –- — i <br /> inspections. Complete drawing on reverse side. u <br /> Signed X ► Title: Date: � 7— i <br /> FOR DEPARTMENT? U_SE ONLY <br /> ( ^ i <br /> Application Accepted by �` Date <br /> Ar <br /> Z , <br /> Pit or Grout Inspection by _ Date Final Inspectioni,by Date <br /> 1I , <br /> Additional Comments: C' ` V 6r(7ir� �f <br /> ❑ 5tk 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.,4P.O. Box 2009, Stk., CA 95291 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK M <br /> INFO �j CASH RE <br /> CEIVEb BY EAT Ee <br /> N0. <br /> + EH 13-24(REV.I)y sl 5.00 •S,, j <br /> EH 14-2a aJ •' D <br /> �� <br />