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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES '{'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 welupump and the Rules and Regulations of the San Joaquin <br /> Local Health District. , <br /> '(� S <br /> Job Address 't r`—' City v Lot Size PM <br /> Owner's Name Address ' �{- Phone �r <br /> Contractor Address S 1 Q icense No, Phone ,? a s <br /> TYPE OF WELL/PUMP: NEW WELL-❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ "" �` SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ` SEWER-LINES.�. DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELD OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL ;PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Y k <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack s❑ Tracy Type of Casing Specifications I <br /> 1-1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout_—. V� <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by <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 ;Below 501 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IR/ADDITION [ I DESTRUCTION I I (No septic system permitted if public sewer is r_ <br /> %{ _.., avawi <br /> ilable iliin 200 feet.) <br /> Installation will serve: Re idence` Commercial Other '` <br /> l <br /> Number of living units: Number of bedrooms j h <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �r <br /> PKG. TREATMENT PLT. ❑ -, Method of Disposal <br /> Distance to nearest: Well Foundation Property Line r <br /> i U <br /> r ri <br /> LEACHING LINE �& Length of lines _ Total Le9th/size Q � <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line \ <br /> i i .•-� , <br /> r <br /> SEEPAGE PITS I ) Depth Size_�� X'�'V x'2 Number <br /> SUMPS - Distance to nearest: Well DuAL4,c Foundation. Property Line r <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 Di1trict. <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 shalt 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 following: "I cernlathe performance of the work for which this permit is issued,i shall employ persons subject to workman's compensa- <br /> tion laws of ifomia. �Thea licant m s al far ali pecti s..C 1 g onre grse side �( ' <br /> Signed X Titl —� Date: <br /> a <br /> FOR DEPARTMENT USE ONLY i <br /> lication Accepted by Date —z— Area 1 <br /> 9 <br /> Pit or Grout Inspection by ate 6 Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> "AMOC7NT"OGE'*""'AMQUNT`fiEAIIITED' CA:::SH c RECEIVED BY �l7ATEPERMIT IVO. <br /> r INFO <br /> +.EH13-24(REV.I H 5l <br /> EH t4-2a <br />