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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT NI) � ( <br /> 1601 E. HAZErL T ON AVE., STOCKTON, CA n <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> (Complete in Triplicate) <br /> i <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 Rules and Regulations of the San Joaquin <br /> I Local Health District.­.I. pa <br /> / / <br /> E!+ f�Y }f f� City Lot Size 4 V jX /2\0 <br /> Job Address PM <br /> e _ <br /> Owner's Name <br /> Address T 4`�, Phone E/G <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW W ❑ WELL REPLACEMENT ❑ DESTRCTUON ❑ <br /> PUMP INSTAL N ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK S LINES DI L FLD. PROP. LINE <br /> FOUNDATION AGRICUL E WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well avation Dia. of Well Casing <br /> El Domestic/Private Ll Gravel Pack ❑ T Type of Casing Specifications <br /> ❑ Public ❑ Other Delta Depth of Grout Seal Type of-Grout <br /> ❑ Irrigation ---Approx. th ❑ Eastern Surface Seal Installed by [ <br /> Repair Work Done ❑ Type of mp H.P. State Work Done vt <br /> Well Destruction ❑ W iameter Sealing Material (top 509 <br /> Filler Material (Below 50'I <br /> IV <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION INo 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 r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line �. <br /> LEACHING LINE ❑ No. & Length of lines Total length/slze <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that Ihave 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 /> fy that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I card <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 /> I' 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." i ~ <br /> e app t must call for all requi inspections. Complete Owing on reverse side. �— <br /> Si netl Title: N Date: <br /> 9 <br /> OR DEPARTMENT USE ONLY : © rte` <br /> I '3,._ :�J�� Area. <br /> Application Accepted by Date t-� <br /> Date Final Inspection by ` x Dat 7 <br /> i Pit or Grout Inspection by �— , <br /> Additional Comments:R � - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 104 ❑ Tracy 83540% <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 C SH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13.241REV.1/ssl 4°' � .. V C3A-7/,Z-7 <br /> EH 14-26 <br /> r <br />