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APPLICATION FOR PERMIT <br /> t t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA POk /L <br /> `. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �3 31Z <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 scri ed. his 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 <br /> Local Health District. <br /> + <br /> Job Address �!� JI,� City<5�ct� Lot Size PM <br /> Owner's Name �+ �f� t'l� Ch - Address Of V\ Phone <br /> Contractor �� _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 LINES DISPOSAL FLD. PROP. LINE <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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public LI Other H Delta Depth of Grout Seal Type of Grout <br /> ­ <br /> i I Irrigation ­Approx.,Depth t 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 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RE.PAER/ADDITION I I DESTRUCTIONAl (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 /> i PKG. TREATMENT PET. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well Foundation T Property Line <br /> SEEPAGE PITS 1 1 Depth Size Number <br /> i SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> I 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 Dltrict. <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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica ust call for squired inspections. Complete drawing on reverse side. <br />{ Signed X Title: Date: <br /> F TMENT USE ONLY <br /> 111' Application Accepted by Date �" a <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> 170 <br /> Additional Comments: <br /> 1 ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED E3Y DATE PERMIT NO. <br /> INFO �f �i <br /> ♦.EH 13-241REV.r/x51 "ice �� y �V `� �' . `v E/0 <br /> EH 14-28 <br />