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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA SCANNED <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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 well/pump and the Rules and Regulations of the San Joaquin it <br /> Local Health'District. <br /> Job Address © Z , Citu oi Size PM <br /> Owner's Name Address Phone i <br /> Contractor _ P.r Address License No4 Phone <br /> 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-Elf <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> j' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS . <br /> � INTENDED USE � TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing {y <br /> i ❑ Domestic/Private .' ❑ Gravel Pack ❑ Tracy Type of Casing Specifications y 1 <br /> L ❑ Publican. / ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> EJ Irrigation ! ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> i Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') * 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> L <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units:4— Number of edrooms t <br /> I <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. ❑ p a Method of Dlspo§al <br />[ Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i FILTER BED ❑ Distance to nearest: Wellr DC7 Foundation Property Line 73Z2 <br /> 1 , <br /> v' SEEPAGE PITS ❑ Depth ize Number <br /> fU_M­P> ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O { <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 /> r rules and regulations of the San Joaquin Local Health District. , <br /> .,.. <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 <br /> } employ any person in such manner as to became 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 mat call far II r ire ins do s. Complete dr g on reverse side. <br /> f Signed itle: Date: ' <br /> FOR DEPARTMENT USE ONLY r� <br /> Application Accepted by �;/� � Date `��—" / Ar/a— <br /> Pit <br /> or Grout Inspection by Date ,L—Cf� L,��. Final Inspection by Date!_ _�'..a <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE- AMOUNT REMITTED .ASH RECEIVED By DATE PERMIT N0. <br /> + EH 13-24(REV.3/e 51 <br /> EH 14-25 <br />