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r <br /> APPLICATION FOR PERMIT <br /> . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I � <br /> 1601 E. WAZELT ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t Application is hereby made to the San Joaquin Local Health bistrict 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 /> (TYPE <br /> ob Address Ci y Lot Si a `�-' PM <br /> r Phone <br /> � Owner's Nam Address <br /> Contractor �' Address License No. Phone_ <br /> OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTAN AREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE <br /> TION AGRICULTURE WELL OTHER et!W PITS/SUMPS <br /> INTENDED USE TYPE OF WELL EM AREA CONSTRU ECIFlCATIONS <br /> f ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing <br /> t ❑ Domestic/Private ❑ Gravel Pack cy Type o Specifications <br /> f-1 Public H Othe Cl Delta Depth of Grout Sea Type of Grout <br /> I I Irrigation --_Approx. Depth I I Eastern Surface Seal Installed by - <br /> Repair Wor ne ❑ Type of Pump H.P. State Work Done — <br /> I estruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50'1 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is <br /> F available within 200 feet.) <br /> I a <br /> F <br /> installation will serve: Residence_ Commercial� Other <br /> Number of living units: Number of bedrooms Q� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments or <br /> PKG. TRE=ATMENT PLT. ❑ ` Method of Disposal J <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 1 I Depth Size T Number <br /> j 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 in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Diltrict. <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."Contractors hiring or sub-contracting signature <br /> certifies the following: 1 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 for all require inspections. Complete drawing on reverse side. Q� GrII ! <br /> Signed X f Till Date: V <br /> ' FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by — Date <br /> Additional Comments: <br /> C7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH 1 <br /> 3-24(A EV.riR51 <br /> EH 1428 <br />