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APPLICATION FOR PERMITS <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> N Telephone Q09) 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 / ~� ov� City, Lot Size / ;142 `� PM <br /> Owner's Name Address -� � � Phone (.a <br /> v <br /> Contiactor Address License No. Phone <br /> TYPE OF WELL/PUMP:., NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑DISTANCE TO TO NEAREST: SEPTIC TANK R LINES L FLD. PROP. LINE <br /> FOUNDATION AGRICULTU OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROS REA CONSTRUCTION SPECI S <br /> ❑ Industrial ❑ Open Bottom Manteca pia" of Well Excavation of Well Casing <br /> ❑ Domestic/Private ❑ Grave c ❑ Tracy Type of Casing Specifications <br /> i`l Public ther Ll Delta _ Depth of Grout Seal Type of Grout <br /> I I Irrigation �_Approx. Depth ! I Eastern Surface Seal Installed by <br /> Repair Wor one ❑ Type of Pump H.P. State Work Done_ A� <br /> Well struction ❑ Well Diameter Sealing Material (top 50') A <br /> Depth Filler Material (Below 501 r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION i (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will server"Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth y <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> ii <br /> Distance to nearest: Well Foundation Property Line <br /> f • <br /> LEACHING LINE ❑ No. & Length of lines_ Total length/size <br /> FILTER BER ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS t I Depth Size Number <br /> 4 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 /> 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 1 p on laws of California."Contractor's hiring r <br /> . o sub contracting signature <br /> certifies the followrn . "I certify that in the performance of the work for 9 9 9 <br /> g Y pe o which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mustcall for all required inspec'ons. Com <br /> � q pe pato drawing on reverse side. / C/�y <br /> Signed X Title: � G / <br /> - _ Date: <br /> FOR DEPARTMENT USE ONLY 7 <br /> Application Accepted by _ Date 1 Area Dd- <br /> Pit or Grout Inspection b Date Final Inspection by Date <br /> Additional Comments: <br /> Cl Stk 466-6781 171 odi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Bax 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> ♦ EH13.24(REV.I/K5) 3S.�a `,01D <br />