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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (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/of install the work herein described. Tins application is <br /> made in compliance with San Joaquin County Ordinance No.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address tCity- Lot Size � PM <br /> Owner's Name Address 4f <br /> 4N !~ Phone <br /> Contractor's Name gnqLicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENY ❑ 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth,of Grout Seal Type of Grout <br /> EJ Irrigation ---Approx. Depth L3 Eastern Surface Seal Installed 13y VV <br /> Repair Work Done ❑ Type of Pump <br /> H-P. <br /> State}Work Done G <br /> Well Destruction ❑ Well Diameter _ Sealing Material (top 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is 1 <br /> available within 200 feet.l <br /> Installation will serve: Residence commercial— Other � <br /> Number of living units: Number of bedrooms 0 . <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. El 41�!�X" . ^ Method of Disposal <br /> Distance to nearest: Well� Foundation. .D Property Line <br /> N. ' . v$ <br /> LEACHING LINE No. & Length of lines dotal length/size <br /> FILTER BED Distance to nearest: Well. !d Foundation y_ Property Line `� 4 <br /> 1 <br /> SEEPAGE PITS � Depth __Size Nu e <br /> SUMPS ❑ Distance to nearest: WellFoundation Property Line ._ <br /> DISPOSAL PONDS ❑ ' <br /> I hereby certify that I have prepared this application and that the work will be done in accord!A b wij�1 ItMn Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> il <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 CaI'ftorn "Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which'this peynit is issued sh I employ persons subject to workman's compensa- <br /> tion laws of California," <br /> •`. • •r. + u <br /> The applicant ust c for all require pections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY r� <br /> Application Accepted by Date � Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 00, �w <br /> 95-W' 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 <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 RECEIVED BY DATE PERMIT"N0. <br /> INFO CASH <br /> +EH 13.24(REV.10/83) ` ..5 <br /> EH 74-26 <br />