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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZELTON AVE.., STOCKTON, CA <br /> Telephone (209)'466-6781 <br /> PERMIT EXPIRES VYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) - . <br /> a. R <br /> f made to the San Joaquin Loca1.l Health•Dist rict for a permit to construct and/or install the work herein described.TMs application is <br /> Application is hereby with ty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance San Joaquin Co <br /> Local Health District. A r 1 { <br /> - 1 <br /> -- Lot Size,. PM <br /> City <br /> jzz�z Job Address / f <br /> IN Address - `- Phone <br /> Owner's Name <br /> Contractorddress <br /> icense No� Phone B <br /> TYPE OF WELL IPUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHER ❑ <br /> P. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC S Dia of Well Casing <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well 1 xcavat <br /> T of Ca ' Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack [J Tracy Type T of Grout <br /> ❑ Public EJ Other ❑ Delta D of Grout Seal Type <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done— <br /> Well Destructio ❑ Well Diameter Seaiing Material {top 50'1 <br /> �;�,.�,,..,.—�. Filler Material (Below 50') --... - - - F <br /> Dept <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION availablelwt withinyst200 permitted if public sewer is <br /> Installation will serve: Residence— Commercial, Other <br /> Number of living units: Number,of bedrooms <br /> , Water table depth 10!y <br /> T <br /> Character of soil to a depth of Veet" I No. Compartments <br /> z, Capacity <br /> SEPTIC TANK �.j ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Property Line <br /> Distance to nearest: Well Foundation � <br /> E >r 3Total length/size <br /> LEACHING LINE ❑ No. & Length of lines ; <br /> E Property Line <br /> FILTER BED . ❑ Distance to nearest: i'Well Foundation i <br /> Number.,._ <br /> .. � <br /> SEEPAGE PITS ,.'❑... Depth 'Size Property Line f <br /> ` SUMPS ❑ Distance to nearest:' *Well Foundation <br /> 4; <br /> DISPOSAL PONDS ❑ <br /> Thereby certify that l 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, 1 shah 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." 4, �L <br /> The applicant must for all requir m - ctions:-Complete drawing en rse side. <br /> ' Title: Date: <br /> Signed <br /> F R DEPARTMENT USE ONLY <br /> Date Are <br /> Application Accepted by �4 <br /> Pit or Grout Inspection by <br /> Date�— Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466 6781 ❑ Lodi 369 3&21 ❑ Manteca 823-7104 C3 Tracy 835-6385 <br /> r Applicant Return all copies to: Environmental Health Permit/.Services 1601 E. Hazelton Ave`, P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> t EH 13-241REV.1/86l <br /> 4(35 IS-7-ss <br /> EH 1426 <br />