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' APPLICATION FOR PERMIT <br /> yY ►`��tS <br /> SAN .}OAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED F{1� <br /> r (Complete in Triplicate) d� , <br /> Application Is hereby mads to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. T application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for we <br /> and the Rules and Regulations of t e San Joaquin <br /> Local Health District. <br /> City Lot Size PM "#r <br /> Job Address [� <br /> �. n Phc�� <br /> Owner's Name Address <br /> Contractor Address <br /> 1v License < ( a�r Phr <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL \ I <br /> INTENDED USE TYPE OF WELL - ' 'PR08LEM AREA--d( NSTRUCTION SPECIFICA \ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel.Pack ❑ Tracy Tasing Specifications <br /> FI Public f ! n Other C1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. D ,,,J Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ T ump} H.P. State Work Done <br /> Well Destructi Well Diameter' Sealing Material (top 50'1 <br /> R Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION ( I DESTRUCTIO (Nailahperw Thin 200 feetstem .) <br /> if public sewer is 1 t� <br /> Installation will serve: Residence—i Commercial__Other \� <br /> a <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br />! SEPTIC TANK C1Type/MfgCapacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ,�`- Method of Disposal <br /> Distance to nearest: Well s Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ---Weil-. ­—Foundation Property Line <br /> E PITS l I Depth Size Number. <br /> SEEPAGE <br /> SUMPS Ll Distance toE 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 /> k 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 /> f 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 for which this permit isue <br /> issd,I shall employ persons Subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call for all required inspections, Complete drraWi,nngg on re side <br /> Signed `Title Date: <br /> ' FO pARTMENT USE ONLY <br /> Date ` Area <br /> Application Accepted by r x <br /> } Date Final Inspection by _ Date p O fJ <br /> Pit or Grout Inspection by <br /> I <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 835- <br /> 6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Box 2009, Stk., CA 95201 <br /> l FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT�NO. <br /> INFO / CASH �i�rCl7 <br /> ..EH 13-24IpEV.rinbl <br /> EH 14-2e ✓✓✓ <br /> 5 <br />