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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH 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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address * <br /> City .Lot Size PM <br /> Owner's Name q ►`� b 32 3 <br /> Phone <br /> Contractor ress 'rLicense No3W �Phonef <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LS DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICU TURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE A A CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications <br /> El Public El Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —4 rox. De th - <br /> PP ❑ East n <br /> P Surface Seal Installed b <br /> Y (' <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ �J.► <br /> Well Destruction ❑ Well`,Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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: Water table depth <br /> SEPTIC TANK ❑ Type/MfgCapacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Or Method of Dispo I <br /> Distance to nearest: Well 16_00 Foundation Property Line JA A <br /> UJ <br /> LEACHING LINE ❑ No. & Length of lines ' dotal length/size <br /> FILTER BED ❑ Distance to nearest: Well Wo tion — Property Line _, <br /> SEEPAGE PITS ❑ Depth Size N tuber <br /> SUMPS ❑ Distance to Weare t: Well Foundation� � pr rty 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_wprkmap'i 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 applicagi must call fo, II required inspections. Complete drawing on reverse side. <br /> '. f 2 <br /> Signed X Title: Q Date: <br /> t <br /> FOR EPARTMENT USE ONLY <br /> Ap "cl a Accepted by Date '] <br /> Pit r Grout Inspection Date t.-�-� Final Inspection by - Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT'DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24 IREV.1/8 5) ' I O t1 p^ I[Z1(� -2f 4 <br /> EH 14-28 1 L <br />