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APPLICATION FOR PERMIT <br /> 4 f� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> V``'' d-'-� Telephone (209) 466-.67$1 <br /> t PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED <br /> (Complete in Triplicate) <br /> Apples 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. ti <br /> ' .y Q_ City Lot Size - PM <br /> [JobAddress Per'sPhone �3tractor Address I �� �• �� License No. �Phone <br /> TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 'OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER..LINES­- DISPOSAL- PROP. LINE <br /> FOUNDATION- AGRICULTURE WELL R WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C CT ION.SPECIFICATIONS <br /> Ll Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ y Type of Casing k. Specifications <br /> t T e of Grout Q \ <br /> I. "❑ Public Depth of Grout❑ Other ❑ Delta Seal YR <br /> ` ❑ irrigation x. Depth ED Eastern Surface Seal installed by <br /> r Repair Work D e ype.of Pump H.P. State Work Done � <br /> 4 Well Destruction C1Well Diameter t Sealing Material (top 501 <br /> Depth Filler Material (Below 50')'�. — - –: <br /> �,. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll 'REPAIR/ADDITION,❑ DESTRUCTION (No-,septic system permitted if public sewer is <br /> .j - <br /> h --avai(able within 200 feet.) <br /> Installation°will serve: Residence— commercial; Other ' <br /> 'Wumber of living units: Number of bedrooms <br /> Character of soil to a"de`pth_of 3 feet: Water table depth <br /> ti : No. Compartments <br /> SEPTIC TANK )<Type/Mfg Capacity <br /> i 1 PKG?:TREATMENT PLT. ❑ Method of Disposal 1l <br /> } Distance to nearest: Well Foundation Property Line <br /> I �i <br /> LEACHING LINE = ❑ No. & Length of lines !f Total length/size "= <br /> FILTER BED ❑ Distance:to,nearest:– well+ Foundation Property Line <br /> ' <br /> Number <br /> UW' <br /> EPAGE PITS ❑K Depth Size - <br /> gg . ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereb}%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 /> E rules and regulations of the.San Joaquin Local.Health District. <br /> ify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I cert <br /> T employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 /> The applicant must call for all required inspections: Complete drawing on reverse side. <br /> Signed <br /> t `"–Title _ – —-- Date: c�] z' / <br /> FOR DEPARTMENT USE'ONLY <br /> a►_'�. � � `�Q' Area <br /> Application Accepted by ,� Date <br /> Pit or Grout Inspectio Date Final Insp tion by Date <br /> x r i N <br /> Additional Comments: <br /> ❑ Stk 466-6781 _ , ❑ Lodi 369-3621 ❑ Manteca 823-71 - ❑ 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 CK RECEIVED qY ' DATE PERMIT NO. <br /> INFO <br /> + EH 13-24 1REV.ti i a 57 <br /> EH 1428 - -. <br />