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APPLICATION FOR PERMIT '. J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT € � <br /> 1601 E. 4jAZV�,TON\,6-E , STOCKTON, CA . <br /> Telephone (209) 466-6781 , <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED ENTAL H>�ALTH <br /> (Complete in Triplicate) EJAN --WERVICES <br /> jj"9�it>`ecT, This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weli/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. r <br /> City of Size PM <br /> Job Ad ` , <br /> 7I <br /> Address ___ Y1_ Phone <br /> r. + <br /> Owner' Name <br /> © r F Phone <br /> Contractor ress �. License No, : <br /> TYPE OF WELL/PUMP: NEW ELL © WELL REPLACEMENT ❑ DE531PUCTION ❑ <br /> SYSTEM REPAIR �y OTHER ❑ <br /> PUMP INSTALLATION ❑ e 'F' <br /> DISTANCE TO NEAREST:SEPTIC TANK ` SEWER.LINES_- <br /> spISP�SAL FLD: PROP. LINE <br /> AGRICULTURE WELL -� r'_OTHER WELL PITS/SUMPS <br /> FOUNDATION } (� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT!2N ►J �+� <br /> �G,I. :Dia.•of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �,r i a <br /> Type of Casing—_L— <br /> F1 <br /> asing ' Specifications <br /> t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> r n Delta Depth of Grout Seaff <br /> F1 Public ❑ Other <br /> r i 1 Irrigation - '..Approx. Dept l I (astern Surface Seal Installd by <br /> Repair Work Done / •��� H. _� i ' State Work Done <br /> Type of Pump .�; <br /> Well Destruction ❑ Weil Diameter Sealing Material )top 50'i <br /> Depth Filler Material (Belowperm50j1 <br /> r c System <br /> TYPE OF SEPTIC WORK ^NE ,.INSTALLATION l l f3EPAIR/AQQITION l 3 DE&TRrf1CTI0N I i aNaifahperwthin 200 feet.) it public sewer is <br /> + Installation will serve: Residence 6 'Corhm arm•tial'--Other I <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> Capacity ~fir-N_o;Compartments <br /> r SEPTIC TANK _ ❑ Type/Mfg - <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> r <br /> I FILTER BED ❑}' Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS -Ll 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 requiati s of the San Joaquin Local Health District. <br /> Home owner licens agent's signator certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> ¢ employ any arson in su manner as t eco lett to workman's compensation taws of California."Contractor's hiring or sub contracting signature <br /> I certifies th tollowiIF "I ertify Th/in pe omma ce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> 1 <br /> tion laws f Califor ia." <br /> The app)tan u a .for all qui c' �ewdrawrng on r e i e. <br /> Title: Date: <br /> Signed X <br /> FO PART ANT USE ONLY <br /> } � � . . <br /> ' Date Area <br /> Application Accepte <br /> EC <br /> Date Final Inspection <br /> Pit or Grout Inspection by <br /> ' Additional Comments: <br /> ❑ Stk 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, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED' CASH <br /> 4 ♦.EH 13-24IREV.7tine1 <br /> EH 14-28 _ <br />