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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCACHEALTH DISTRICT <br /> 1601 E. HAZELTON 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 Ryles and Regulations of the San Joaquin <br /> + Local Health District. <br /> Job Address r c <.. <br /> City Lot Size PM <br /> Owner's.Name Address W Phone- <br /> ' Contractor Address S� License N 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing F Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal s Type of Grout <br /> C1 Irrigation <br /> --Approx. Depth ❑ Eastern Surface Seal Installed by A. <br /> Repair Work Dane ❑ Type of Pump H.P. State Work Done f <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') J <br /> j <br /> Depth ' Filler Material (Below <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONNo 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: ✓ <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ! Method of Disposal 1� <br /> Distance to nearest: Well • Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER SED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth 7 Size Number <br /> 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 District. s <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 p <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 I <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 /> The applicant must call for all r fired ' spec'o s. Complete drawing on reverse side. �y 7Signedd° " Title Date: 'cf3s�� <br /> FOR DEPART T USE ONLY <br /> Application Accepted by. �✓ Date ?0 <br /> A a <br /> �.- <br /> Pit or Grout Inspection by ate Final Inspection by_ Date& `--Z <br /> ,Acldftional Comments: ;4 <br /> Stk 466-6781 ❑ Lodi 3fi9-3621 12 Manteca 823-7104 ❑ Tracy 835-63851 <br /> Ap icant- Return Al copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,.CA 95201 <br /> FEE <br /> NFO <br /> AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> I <br /> sU <br /> +EH i3-S24(REV.t/6s1 O�lf <br /> k. EH 1446 � - - 0 \. 6 O � <br />