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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. _ <br /> 1 r City G Q ',Lot Size G a X 7 5- PM <br /> Jab Address <br /> f 1 <br /> r- rtfAOQ�. �4 AddressPhone Owner's Na:A,6k( <br /> Contractor <br /> Addre Ucense No, Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation <br /> T e of Casing Specifications <br /> ❑ Domestic/Private Ll Gravel Pack EJ Tracy YP g Type of Grout <br /> n Public F1 Other ❑ Delta Depth of Grout Seal yp <br /> i 1 Irrigation —Approx..Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material IBolow 50') <br /> tl TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I i DESTRUCTION i ;No septic sy t m perm <br /> ieetitled if public sewer is <br /> Installation will serve: Residence_ Commercial— Other <br /> i Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ TypelMfg Capacity No. Compartments <br /> w Method of Disposal <br /> PKC. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> length/size <br /> leng <br /> LEACHING LINE ❑ No. & Length of lines To � <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS l 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 Di§trict. <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."Contractor's hiring or sub-contracting signature <br /> i 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 /> I The applicant must call t qu 6-inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> i <br /> I FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by '1 r' <br /> �I Pit or Grout Inspection by to_l .. Final Inspection by Date <br /> k Additional Comments: <br /> ❑ Stk 466-6781 El Lodi 369-3621 El Manteca 823 7104 ❑ Tracy 635-6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ffFEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> ASH <br /> +.EH 1324(REV.1/H 54 <br /> 17 <br /> EH to-28 <br /> L <br />