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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE-iON AVE.,' STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES1 YEAR FROM DATE ISSUED <br /> Ji (complete iii Triplicate) ` ` 5 <br /> - <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.­OSWL' <br /> Job Address �� } _ City 'Lot Size` PM ` <br /> y� ;� . <br /> Owner's Name Address Phone' <br /> Contractor � ile' # AddressLicense No.�A3�L3 Phone —'y v <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR H' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER"LINES DISPOSAL FLO. " 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 /> ,2 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Public ID'Other ❑ Delta Depth of Grout Seal Type of Grout i <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by i <br /> Repair Work Done is Type of Pump_-4l� H.P. State Work Done <br /> Well Destruction ❑ Well Diameter: Sealing Material {top 50'1 <br /> Depth Filler Material iBelow 501 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> r available within 200 feet.l <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: :k Water table depth <br /> SEPTIC TANK ❑ Type/Mfg- Capacity -No. Compartments - - <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ,3 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> � t <br /> SEEPAGE PITS ❑ - Depth -Size Number <br /> -SUMPS- ❑ Distance to nearest:='Well Foundation - Property Line' <br /> DISPOSAL PONDS ❑ y <br /> I hereby certify that I have prepared this application and that the work will be'- one in accordance with San Joaquin county ordinances, state lbws, 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 /> j certifies the following:"t 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 /> r <br /> The applicant must call for all required inspections. Complete drawing on rev se side. <br /> Signed Title: U <br /> F R DEPARTMENT USE ONLY <br /> �`�' <br />{ Application Accepts y � � Date Area <br /> t y <br /> Pit or Grout Inspecti y Date Final Inspection by Date �' �y <br /> -,. ,. <br /> - n � <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 t-y <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA'401 P, , <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`N0." , <br /> +EH 13-24(REV.1/a5) <br /> EH 1426 ✓_ G <br />