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I <br />+ APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {2091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 1 <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 He lth District. <br /> Job Address ty Lot Size PM <br /> Owner's Name Address=T "' <br /> -_� _ ,. Phone <br /> I Contractor f ddress License No ` Phone <br /> TYPE OF WELL/PUMP: n NEW WELL ❑ R .WELL,REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION.,❑ �SYSTEM REPAIR ❑ OTHER ❑ \ <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP. LINE v <br /> 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 <br /> F <br /> ❑ Domestic/Private El Gravel Pack L1 Tracy Type of Casing � Specifications � <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ 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 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> • N available within 200 feet.) <br /> Installation will serve:. Residence'�z Commercial - Other r * lJe �o <br /> i <br /> Number of living units: Number of bedrooms + <br /> - <br /> i Character of soil to a depth of 3 feet:. Water table depth <br /> k SEPTIC TANK. ❑ Type/Mfg _ Capaci No. Compartments <br /> 4 PKG. TREATMENT PLT.❑ _' Method of Disposal <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: WeII Foundation Property Line <br /> SEEPAGE PITS ❑ .. Depth Size Number <br /> SUMPS 4 ❑ Distance to nearest: Well Foundation Property Line <br /> k DISPOSAL PONDS ❑ t <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 /> I 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." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California. <br /> The applicant must call fo "II a ireo Inspections. Complete drawing reverse side. -� <br /> Signed <br /> Title: ` Date: V <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C►�S� Date e Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> + ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-SM <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 40 RECEIVED BY DATE PERMIY'NO. <br /> i INFO q 7 <br /> } +EH 13-24{REV.1/8 <br /> a 5l to } �] � �� -V {�� gs^�d7 <br /> EH 14-26 J <br />