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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> "� II 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> APERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> hi (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. 1562 forell umpfa�the Ru! and Regulations of the San Joaquin j <br /> Local Health District. 4 �� <br /> r <br /> Job Address City Lot Size <br /> a <br /> Owner's !Name � ddress S a ( Phone <br /> �-j•� <br /> Contractor's Name � ® � License No. �. I ?Z � ? Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ — <br /> INTENDED USE _- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS h° <br /> k ❑ Industrial ❑ Open,Bottom '411 Manteca Dia. of Well Excavation ;.Dia.-of-Well Casing___-- - -� <br /> ❑ Dornestic/P�ivate �❑ Gravel Pack ❑ Tracy Type of Casing., 0 .. Specifications <br /> ❑ Public ElOther ! C1 Delta Depth of Grout Seal Type of Grout <br /> 3tion —Approx. Depth I] Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pum H.P. State Work Done ' <br /> p p <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth :! Filler Material IBelow 501 ' n- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 0 INo 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 /> E SEPTIC TANK ❑ Type/Mfg <br /> Capacity— <br /> r Ca aci No. Compartments <br /> PKG. 'TREATMENT PLT. ❑ lir 1 Method of Disposal <br /> Distance';to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth 'Size Number <br /> SUMPS ❑ Dlstance`to nearest: Well FoundationProperty Line <br /> DISPOSAL PONDS ❑ !f s i P <br /> I-hereby-certify that-I-have.prepared-this=application and-that-the workL will-be-done-in,accordance-with_San.Joaquin county_ordinances,_state-laws, and_ <br /> i rules and regulations of the San Joaquin Local Health District, a <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perm(#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 /> certifiers 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 /> The applicant st I,If requuiired i�nspe/�ons. Complete drawing onreverseside. ` <br /> Signed X_ Title: v v Dater <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> C J! �� _ Area <br /> _ <br /> Application Accepted by '� Date— 7 <br /> „ JJ <br /> Pit or Grout Inspection by Date Final Inspection by :,t— �.� <br /> Additional Comments: <br /> i <br /> -;0 SO, 466-&781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 CI Tracy 535-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BoR 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> a9 N. __�`I Sl <br /> /G <br /> +EH 1324(REV.10183) <br /> �p 03 <br /> " EH 14-26 <br />