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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 andlor install the work herein described. This application is r <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for Weil/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �I <br /> r <br /> Job Address <br /> �.� e CityC of Size PM <br /> E " f f <br /> f Owner's Name Address /� P y Phone <br /> �A I Address License No. Phone <br /> Contractor Sri <br /> TYPE OF WELL/PUMP: I�, NEW WELL El WELL REPLACEMENT 11 <br /> ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br />° DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPO5 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS } <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS <br /> D LiDia. of Well Casing <br /> ❑ Industrial Open Bottom Mant Dia. of Well Excavation f <br /> S ecifications <br /> El Domestic/Private ❑ Gravel Pack racy Type of Casing p ;/�. <br /> 17 Public F] Other Cl Delta Depth of Grout Seal Type of Grout V 1 <br /> I I Irrigation prox. Depth I 1 Eastern Surface Seal installed by- <br /> Repair <br /> y Repair Work Done Type of Pump H.P. State Work Done <br /> I Well Destr ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK:,. NEW INSTALLATION I I HEPAIR/ADDITION I I DESTRUCTION I iNo septic system permitted if public sewer is <br /> available within 20(3 feet.) <br /> l installation will serve: Re I�idence Commercial_ Other <br /> Number of living units: ' !M Number of bedrooms - <br /> "k Water table depth <br /> t Character of soil to a depth of 3 feet: <br /> I SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑: .n Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> . LEACHING LINE ❑! i No. & Length of lines <br /> ' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> a <br /> t SEEPAGE PITS �Q!�. Depth Size - Number <br /> SUMPS �L- 11 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 District. <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 /> j compensation laws of California."Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's <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 /> l The applica tail for all required ns ctions. Complete drawing on reverse side. 4: <br /> �! <br /> Signed X Title: Date: <br /> II FOR DEPARTMENT USE ONLY �rsw <br /> Application Accepted by,i: I Date Area �j <br /> Pit or Grout Inspection �� Date Fina! Inspection by Date s� S v <br /> Additional Comments: I� <br /> ❑ Stk 466-6781 ❑ 1 odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO Q� <br /> + EH 13-24IREV.I/"5f ' �`' 6-r]2oc7 (/U` <br /> EH 14.26 ':I' <br />