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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ' <br /> PERMIT EXPIRES 1YEAR 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. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weliYpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. " <br /> Job Address �FCity Lot Size -5:i2)L-2. PM <br /> Address Phone <br /> o y <br /> Owner's Name Phone z - <br /> Contractor_ k Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER XINEISPOSAL FLD. PROP. LINE <br /> FOUNDATION- AGRICU ..OTHER-WELL.WELL.--PITS/SUMPS <br /> -PITS/SUMPS <br /> INTENDED USE r TYPE OF WELL PROBLEM AREAION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca l Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ing Specifications <br /> f"1 Public 1 1 Other ❑ Delta ut Seal Type of Grout I I Irrigation _ -Approx. Depth I I Eastern l nstalled by 'V <br /> Repair Work Done ❑ Type of Pump ' H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material 18elow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION E I DESTRUCTION I No septic system permitted if public sewer is <br /> 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 /> SEPTIC TANK ❑ Type/Mfg" Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> > Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: " Well Foundation Property Line <br /> SEEPAGE PITS t I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ F >I <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. <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, I shall not l <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 I, <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 applicantAyjmt call for all required ctions. Complete drawing on reverse side. <br /> i � <br /> XSigned ` - Title: �. �� Data: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout inspection by Date Final Inspection by Date f <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 <br /> .,Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. F <br /> INFO J 7 y <br /> + EH 13-241REV. /rsSY �ti'0 1 j.�70 / 40 + <br /> Ell 14-26 1•� <br />