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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) lication is <br /> Application is hereby made to the San Joaquin Local Health District for a permit fa construct and/or install the work herein described.This app <br /> ma <br /> compliance with S <br /> de a an Joaquin County Ordinance No.549 for sewage or No. 1862 for well]Pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, PM <br /> City Lot Size <br /> Job Address / 3 r <br /> - ti Phone <br /> Address <br /> Owner's Name q�3 <br /> Addcense No.�phone <br /> 3 { <br /> Contractor ress WELL REPLACEMENT 11DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL OTHER C1 <br /> SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION 11DISPOSAL FLD/6 PROP. LINE <br /> �--- Jls/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS — Dia. of Well Casing <br /> Dia. of Well Excavation 9q <br /> pen Bottom ❑ Manteca Specifications tf byl Industrial 4y <br /> ❑ Tracy Type of Casing <br /> ❑ Gravel Pack Type of Grout - <br /> �Ioomestic/Private €-! Other ❑ Delta Depth of Grout Seal a <br /> F1 Public Surface Seal Installed by <br /> Irrigation Approx. Depth I Eastern H.P, State Work Do <br /> Repair Work Done ❑ Type of Pump Sealing Material atop 50') <br /> Well Destruction [3 Well Diame Filter Material (Below 5011 <br /> DeQth111-10, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 HEPAIR/ADDITION i ! DES RUCTION l ! avlailableSeptic <br /> wi within 200 feet.) if public sewer is <br /> Installation will serve: Residence— Commercial __ Other �— <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type]Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: <br /> Total length/size <br /> LEACHING LINE 0 No. & Length of I' s Property Line <br /> FILTER BED C1 Distance to n est: Well <br /> Foundation <br /> SEEPAGE PITS I l Depth Size <br /> Number ~ <br /> SUMPS Ll Dist ce to nearest: Well Foundation��– Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared his 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. ify that in the work for <br /> shall not <br /> Home owner or licensed agent's lsignature <br /> to becomes the following:o workman's compensation lawsoof Californiahe Contractor's thiring or sub-contracting this permit is issued, lsignaturre <br /> employ any person in such manner <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 /> applicant m t �equir d inspectio pTete drawing on rev se si <br /> The app Date: <br /> Title: <br /> Signed X <br /> n f? FOR DEPARTMENT USE ONLY <br /> Dateaa <br /> Area <br /> Application Accepted by rDate Final Inspection by <br /> Pit or Grog[ Inspection by n <br /> Additional Comments: <br /> d Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009. Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> EH 13-24 iREV.r Ks1 l �� <br /> EH 14-28 <br />