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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQU.IN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {2091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 �O � City Lot Size _PM <br /> i Owner's Name Address_ Address _ �¢'1��� Phone <br /> Contract o c Address t2 License No.� PZ+_Phone � r <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 El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta DepthofGrout Seal Type of Grout <br /> ! ❑ Irrigation ---Approx. Depth ❑ Eastern Su rface.Seal Installed by <br /> Repair Work Done ❑ Type of Pump pd&&A H.P. /]— State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> DepthFiller Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Num in units: Number of bedrooms <br /> Character of soil <br /> to <br /> dep et: Water table depth <br /> SEPTIC TANK + ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I Distance io-nearese Well dation Property Line <br /> .LEACHING LINE ❑ No. & Length of lines To h/sizes <br /> FILTER BED ❑ Distance to nearest: Well Foundation Prope i' <br /> -i- <br /> SEEPAGE PITS ❑ Depth SizeNumbert <br /> - � 4 <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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. - 3. <br /> i Home owner or licensed agent's signature certifies the following: "I certify-that`in`ttie 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." Contractors 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 fpr all required inspections. Complete drawing on reverse side. <br /> 's <br /> Signed X Title: Date: .<�2 <br /> FOR P TMENT USE ONLY <br /> I Application Accepted by bate Area US <br /> f Pit or Grout Inspection by Cat t f �Finai inspection by Date �Z <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104. ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> r , <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE <br /> FE <br /> EH <br /> + EH 14-24IREV. /x51 <br /> � EH 14-26. (( <br /> All .. <br /> i <br />