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APPLICATION FOR PERMIT <br /> ,1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />�- 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephohe {209) 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 yam-- "` City Lot Size PM <br /> p�0wner's Name �/� C Address ? Phone <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE T_O-NEAR1tiS4"°"`�`EPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPrOFWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1Industrial LlOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 11 Public ❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout <br /> 1 E Irrigation _Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done r <br /> Well Destruction ❑ Well Diameter _ Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION (No 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 <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 Disposalh <br /> Distance to nearest: Well Foundation Property Line ` <br /> LEACHING LINE ❑ Na. & Length of lines Total length/size <br /> +� <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well _ foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 DFstrict. <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, 1 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 /> Theapp cant us t c II fo ll r uired inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: [�'�' Date: <br /> FOR DEPARTMENT USE ONLY �p�Q <br /> D <br /> Application Accepted by � _ Date 6 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date g� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMI7'tJO. <br /> INFO �} <br /> a,EH 13-24(REV.1/k 51 T(_J�J-_� l 3nlLf00 .0U <br /> EH 14-2e <br />