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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s 1601 E. HAZEL T ON AVE., STOCKTON, CA f <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> j 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 /> Local Health District. <br /> Job Address � City Lot Size PM <br /> Owner's Name / Address Phors� <br /> Contractor Address 1c /— ' <br /> License fV -l �Phone <br /> TYPE OF WELL./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONjrc�, <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 1 ` <br /> Js <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of WeI!'Casing �( <br /> ❑ Domestic/Private ❑ Gravel Pack `-C] Tracy Type—of.-Casing \ <br /> 1Spec cations <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T r <br /> 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 /> 4 . <br /> Well Destruction ElWell Diameter , <br /> • Sealing Material <br /> Depth Filler Material (Below 50'}_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is <br /> „- <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: "4 -- - Water table depth r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line - <br /> LEACWING LINE ❑ No. & Length of lines Total length/size t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size' Number <br /> SUMPS ❑ Distance to 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 ir1'acc6rdance with San Joaquin county ordinances, state laws, and W ! <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "t 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 applicant m t call for all requir ins ctions. Complete drawing on reverse side < <br /> Signed .S s � <br /> Title: Date: <br /> FOR DEPARTMENT,USE ONLY 2 � <br /> Application Accepted by s A .Date ��Jy—",Q <br /> 7 Area Q <br /> Pit or Grout Inspection by �7 Date Final Inspection by Date r <br /> Additional Comments: +� a <br /> ❑ Stk 466 8781 ❑ Lodi 369-3621 ❑ Manteca 82:3-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health ermit/Services 1601 E. Haze �n Ave. P.Q. Box 2009, Stk., CA 01 <br /> 41 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> INFO CASH <br /> + EH W24IREV.i/857 { +� 1/t-1 -�/j� 3_36„ <br /> EH 1424 VVV 11 V t <br />