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r 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 installthe work herein <br /> nd Regulations of the San Joaquin described. This application is <br /> made compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules a <br /> Local Health District. <br /> Job Address i <br /> City sloe, mit Size ! <br /> - PM <br /> Owner's Name _ -f11 � �, Address <br /> Phone �► <br /> l <br /> Contractor -6 Address <br /> TYPE OF.WELL, PUM • License No.—Phone <br /> _ _: NEW WELL_d WELL REPLACEMENT ❑ <br /> „'-------� m- r DESTRUCTION C3PUMP INSTALLATION [ISYSTEM REP R40' "DISTANCE TO NEAREST: TANK OTHER ❑ ..,, <br /> SEWER LINES FLD. PROP. LINE <br /> FOUNDATf AGRICULTURE WELL OTHER WELL <br /> INTENDED USE PITS/SUMPS . <br /> TYPE OF WELL 0 " ` <br /> EM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial CJ Open Bottom ❑ Mantec Dia. of Well Excavation <br /> 11Domestic/Private 11Gravel Pack Dia. of Well Casing <br /> ❑ Tracy "p a of Casing <br /> ❑ Public ❑ Other ❑ Deli Specifications <br /> El Irrigation <br /> Depth o out Seal Type of Grout <br /> ---Approx. Depth ❑ EasternI <br /> Repair Work Done ❑ Type of Pumpurface Seal In d by <br /> H.P.HPto Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') s <br /> Depth Filler Material-(Below 50')J <br /> TYPE OF SEPTiC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if-public sewer is <br /> Installation will serve: Residence— Commercial_ Other available within 200 feet.) ; <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ CapacityNo. Compartments <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS El Depth Size <br /> SUMPS ❑ 'Distance Number <br /> stance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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 /> rules and regulations of the San Joaquin Local Health District. <br /> Homo 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."Contractor'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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed , <br /> Title: -, <br /> H, Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by � <br /> Date Area <br /> Pit or Grout Inspection by Date <br /> - i Final Area <br /> by Date <br /> Additional Comments: f 3 <br /> ❑ Stk 466-6781 ❑ Lodi 369- 1 ❑ Man eca 823-7104 ❑ Tracy 5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K <br /> INFO y� H RECEIVED BY DATE PERMIT'NO. <br /> + EH 13.24(REV.1/85) 0 / <br /> EH 14-25 v <br />