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APPLICATION FOR-PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <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 /> :: <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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.; <br /> City Lot Size S1 0 `, tt) PM <br /> Job Address <br /> { { �_r it �.�1f S ddreCC °t- Phone .• <br /> Owner's Name — j - �_Iss-.ss , <br /> Phone <br /> Contractor T Address.vti' License No. <br /> CTION ❑ <br /> TYPE OF WELL/PUMP: . i-. . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU <br /> b - PUMP INSTALLATI ❑f,� SYSTEM REPAIR ElOTHER Q <br /> DISTANCE TO NEARES�:!SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE <br /> FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM CONST TION SPECIFICATIONS <br /> D Industrial Q Open Bottom ❑ Manteca Di f Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy pe of Casing Specifications <br /> ❑ Public ❑ Other r ❑ Delta De of Grout Seal , Type of Grout <br /> ❑ irrigation_ --Approx. Depth Q Easter Surfac Seal Installed by '' <br /> ` i <br /> C Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> E <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material, (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAiR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> avail le within 200 feet.)V <br /> Installation will serve: Residence_ Commercial_ Other � 45 <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 Capaci No. Compartments <br /> PKG. TREATMENT PLT. Elt !f <br /> t Method of Disposal <br /> Distance to nearest: VY undation Property Line <br /> r <br /> k LEACHING LINE ❑ No. & Length of.lines _ Total length/size <br /> FILTER BED Q Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS: ❑ Depth Size - Number <br /> SUMPS ❑ Distance o nearest: - Well y oundation 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. 1 <br /> Home owner or licensed agent's signature certifies the following: "I'�ero 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 /> tio s of California." <br /> e ap 'ca in all f r 11 req 'red%inspections. Com e drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> z FO DEPARTMENT USE ONLY <br /> a y <br /> Application Accepted y <br /> z Date 6 Are <br /> Pit or Grout Inspect ' Date i Final Inspection by Dat <br /> Additional Comments: <br /> ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca '823-7104 ❑ Tracy 835-6385 <br /> i 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 s CASH <br /> * RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-24(REV.Ue57 <br /> EH 1426 <br />