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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Teleph6ne(209) 466-6781 <br /> PERMIT EXPIRES 1°YEAR FROM BATE 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 Ryles and Regulations of the San Joaquin <br /> Local Health District. ryvz` <br /> _ G <br /> �r � /�/N� <br /> r ICY / L ' Lot Size may ' PM <br /> z 11 y�' i <br /> Job Address k" <br /> Owner's Nam <br /> - /ld 'Address .f�/ - -Sr Phone`-" ..�7 '� <br /> Contractor- M Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL E3WELL REPLACEMENT ❑ DESTRUCTION El <br /> k PUMP INSTALLATION ElSYSTEM REPAIR 1:1OTHER El <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> lFOUNDATION AGRICULTURE WELL OTHER WELL POTS/SUMPS <br /> j INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom l] Manteca Dia. of Well Excavation Dia. of Well Casing _ <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth Ll East <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done (� <br /> Well Destruction El Well Diameter Sealing Material (top 501 (" <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L& REPAIR/ADDITION EJ DESTRUCTION&(No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence_ Commercial i Other :.. <br /> Number of living units: Number of bedrooms <br /> I <br /> 1,5.5 Water table depth <br /> l Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ! Type/Mfg Capacity / 00 No. Compartments <br /> PKG. TREATMENT PLT. ❑ % Method of Disposal <br /> Distance to nearest: Well r-O.0 foundation—�..� Property Line // - <br /> LEACHING LINE ❑ No. & Length of lines 6 - Tgtal length/size <br /> FILTER BED Distance to nearest: Well foundation /_– Property Line — <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 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. - <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 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 far which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." ' I <br /> The applica ust call for equirp spec S. Complete drawing on reverse side. <br /> Signed Tit e: Date: <br /> 1 <br /> FO DEPARTMENT USE ONLY <br /> F �6CY�67�G�U�"O, rea � <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date :Final Inspec' n b Date <br /> Additional Comments: <br /> CI Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201, <br /> QCK I <br /> FEE AMOUNT DUE AMOUNT REMITTED C H .RECEIVED BY DATE PERMIT`N0. <br /> INFO <br /> + EH13-241REV.3/651 {�� C']�"-• �.t'? y - ' <br /> EH 1428 <br />