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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 1 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. THs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welt/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 0 City Lot Size <br /> PM <br /> Job Address <br /> — <br /> Owner's N '� Phone <br /> ame Address ��--- <br /> Contractor � �- �_ Address � <br /> dd c� License No Phone-� �' <br /> TYPE OF WE LIMP: � y rNEW-WELL ❑ WELL REPLACEMENT ED DESTRUCTION ❑ <br /> PUMP INSTALLATION PC SYSTEM REPAIR d OTHER ❑ <br /> DISTANCE TO NEAREST:-SEPTIC,TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> 1, yNFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED-USE.+ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial r '` r'' ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of Casin Specifications C <br /> Domestic/Private, LJ - Type <br /> Pack ❑ Tracy 9 <br /> Type of Grout <br /> i-I Public �f CI Other l 1 Delta Depth of Grout Seal <br /> I I Irrigation r:! Approx. Depth 1 Eastern Surface Seal Installed by <br /> Repair Work Dorie 9 Type of Pump <br /> H p. State Work Do a- U.— <br /> Well Destruction ❑ Well Diameter Sealing Material )top 501 <br /> { Depth Filler Material (Below 501 <br /> TYPE 4F SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l 1 DESTRUCTION I I !No septic system permitted if public sewer is <br /> e available within 200 feet.) <br /> Installation will serve: Residence_'',Commercial_, Other C <br /> t <br /> Number of living units: Number of bedroom$ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> ''}S No. Compartments <br /> i SEPTIC TANK ❑ -pet Mfg <br /> Capacity p <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t <br /> Distance to nearest: Well <br /> Foundation ,ProjiertyLine <br /> LEACHING LINE ❑ No,. & Length of lines <br /> e <br /> Total length/siz <br /> FILTER`BED f ❑ d'Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I i Depth `` Size_— Number <br /> SUMPS-- t �' L1 Distancetonearest: Well Foundation- Property Line <br /> y <br /> F DISPOSAL PONDS ❑ €�' '` <br /> I hereby certify that I have prepared this application and that the work willbe done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. i <br /> Home owner or licensed agent's signature certifies the following: A.I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ ariy 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 i5 issued, I shall employ persons subject to workman's compensa- <br /> tion <br /> laws of California." <br /> The applic all for all require specti S. Co ete drawing on averse side. <br /> Signed XVic <br /> 9 FTitle: 7 -S Date: <br /> FOR DEPARTMENT USE ONLY l <br /> Date <br /> ! Area (� <br /> Application Accepted by a <br /> Pit or Grout Inspection by Date Final inspection by R Date <br /> Additional Comments: <br /> ❑ 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 AMOUNT DUE AMOUNT REMITTED C K 4 RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> a.EK 13-21(REV.I/H 5) <br /> EH 14-26 <br /> -..ems <br />