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APPLICATION FOR PERMIT .PAYMENT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED <br /> 1601 E. HAZELTON AVE., STOCKTON, CA �� <br /> Telephone.(209) 466-6781 4 NOV 1' <br /> 87 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ' ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES..- <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 /> Local Health District. <br /> Job Address CityLot Size PM <br /> AO <br /> Owner's Nar� 416 ddress R <br /> Conlractosddress License No. Phona <br /> TYPE OF WELLIPUMP: NE ,WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION'❑ <br /> PUMP INSTALLATION IF SYSTEM REPAIR'0 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLO. PROP. LINE <br /> r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \ t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t V <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia--of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Grave! Pack Tracy Type of Casing Specifications <br /> i', Public 171Other 171Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _..Approx. Depth l 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 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 iNo septic system permitted it public sewer is <br /> available within 200 feet.I <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 /> RKG. TREATMENT PLT. L] Method of Disposal f <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines. Total length/size <br /> FILTER BED ❑ Distance to nearest: Well_ + Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size {' J' _ Number <br /> SUMPS L� 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 iri accordance with San Joaquin county ordinances, state laws, and <br /> 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call f all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date F f <br /> FOR <br /> �DEP"TMENT'USE ONLY 6 <br /> Application Accepted by Date Area 4 <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional-Comments; <br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services`1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. } <br /> F EN 13-24 1REV.5/H 5) <br /> EH 1428 <br /> �`/�� 0 <br /> # <br />