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+ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> t 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> f <br /> Job Addres� City Lot Size PM <br /> p <br /> Owner's fjl�me <br /> � Address , Phone 6 <br /> r Address License No. Phone <br /> Contractor ` <br /> I TYPE OF WELLlPUMP: NEW WELL 71 WELL REPLACEMENT ❑ DESTR TION C3 <br /> l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS L LLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF.WELL PROBLEM AREA CONST TION SPECIFICATIONS <br /> 13Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> I <br /> Specifications <br /> ❑ Domestic/Private El Pack ❑ Tracy Type of Casing <br /> 1 <br /> I'1 Public 171 Other ❑ Depth of Grout Seal Type of Grout--- <br /> I <br /> rout —I i Irrigation Approx. D I 1 Eastern Surface Seal Installed by— <br /> State <br /> I H.P. State Work Done <br /> umpJ• Repair Work Done LZ <br /> Well Destruction Well Diameter Sealing Material (tap 501 J, <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i REPAIRlADDITION I ! DESTRUCTION (No septic system permitted if public sewer is <br /> i available within 200 feet.) <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 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I' Distance to nearest: Wellndation Property Line <br /> LEACHING LINE ❑ Ida. & Length of lines � 'Nt A, •_ _ Total lengthisize <br /> s FILTER BED ❑ Distance to nearest: Well ""t 'Foundation Property Line <br /> i <br /> r <br /> f SEEPAGE PITS l I Depth Siie Number <br /> SUMPS D 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 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> t he applicant m r all required in Itins, Complete drawing on reverse side. <br /> ad X Title: Data <br /> FOR DEPART ENT USE ONLY <br /> r 'f lL <br /> I Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> C� Stk 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., P.O. Box 2009, Stk., CA 95201 <br /> ` FEE 7 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIYNO. <br /> 4 4 <br /> t + EH 13-241REV.riH51INFO <br /> EH 14-28 <br />