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'r^ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i 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/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 -1- CitZePwo�v� ' Lot Size PM <br /> Owner's Nam • Address lZr Phone <br /> R SSS" <br /> Contractor =,ri Address • 4 D+ <br /> License fQ Phone <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 /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ('1 Public Cl Other f 1 Delta Depth of Grout Seal <br /> Type of Grout ___ <br /> i I Irrigation ­Approx. Depth [ I Eastern Surface Sual Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i'I REPAIR/ADDITION i I DESTRUCTION *'MO septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial— Other available within 200 feet.) Ln <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 r <br /> PKG. TREATMENT PLT. ❑ �. �" Method isposal V' <br /> +� Distance to nearest: Well Fun do Prop i <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total lengt /size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 Di$trict. <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 su anner as to becomes ct to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: " ertify that in the perf ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Califor ' <br /> The applic t m II for all require ctions. m drawing on re se si <br /> Signed Title: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date A_rea <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Silk 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, Silk., CA 85201 <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y <br /> INFO CASH DATE PERMIT'NO. <br /> + EH 13-24(REV.F i H 51 �� 1 <br /> EH 1429 <br />