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{ APPLICATION FOR PERMIT C S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,,STOCKTON, CA <br /> E -Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 'YEA FROM DATE-fSSUEI]...., <br /> •� ' <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. 1,862 for well/pump and the Rules and Regulations of the San Joaquin <br /> " Local Health District. <br /> Ji <br /> Job Address f / �/ <br /> " City 7 ,of Size 6 /1 PM <br /> 3 Owner's Name /1?/ t �Odd'ress' <br /> Phone � r <br /> r <br /> i Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE T EAREST: SEPTIC TANK SEWER LINES DISPl1SEkt'FC� PROP, LINE <br /> OUNDATION AGRICULTURE WELL O HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF PROBLEM AREA N1STRUCTION SPECIFICATIONS <br /> ❑ Industrial , ❑ Open Bottom s17jaea'-' Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ G"ra"vel Packs=. �'. -Tracy T g Specifications <br /> ❑ Public Type of Casing <br /> I ❑ Other a ED ., V Dep f Grout Seal Type of Grout <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Sea alled by <br /> Repair Work Done Type of Pump H.P. tate Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NE'W INSTALLATION ❑ REPAIR/ADDITION ElDESTRUCTION o septic system permitted if public sewer is <br /> - <br /> Installation will serve: Residence— Commercial— Other available within 200 feet.) <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 rt No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: *'Well Foundation - Property tine <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS ❑ Depth ' 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. <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 California." Contractor's hiring or sub-contracting signature <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 appl n 9by <br /> in ti Complete drawing on rev rse side. �J <br /> Signed X Title: Date: <br /> � FOR DEPARTMENT USE ONLYApplication AcceptDate / AreaPit or Grout Inspecony Date Final Inspection by Date(J . <br /> z___ Additional Comments .: <br /> T.. <br /> �._ . - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 835-&M5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Flazalton ve., P.O. Box 2009, Stk., C 95201 <br /> ►- <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERnN�. <br /> INFO /3 �-+EH 1324(REV.4 e 5) r%oQ - <br /> EH 1429 �J v <br />