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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 1 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 /> y -!Z-s-ice <br /> Job AddressL rty Size PM <br /> Owner's Name Y/C, Address Phone <br /> Contractors "", Address 7 ! AA License Nol(u 39� w �'Phone / Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT E WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE 3 TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS <br /> ❑ Ind istrial W Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy d Type of Casing Specifications <br /> M Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> --- <br /> I I Irrigation _.Approx. Depth 1 I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Dimeter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADQITION I I DESTRUCTIO I 1 (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/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. F111 �� Method of Disposal C, <br /> Distance to nearest: Well�T Foundation�,( _ Property Line 200 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 120 f" <br /> FILTER BED ❑ Distance to nearest: Well � Foundation_% /a. Property Line <br /> SEEPAGE PITS I I Depth J Size_ Number <br /> SUMPS <br /> SUMPS L] Distance to nearest: Well 11. 0 Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 applicant ust call for all re fired inspe tions. Complete drawing on reverse side. _ �^ <br /> Signed XTitle: G�i Date: 7U� <br /> FOR DEPARTMENT USE ONLY <br /> 6Adt <br /> pplication Accepted by ` ` Date Area r <br /> or Grout Inspection by Date Final Inspection b D tditional Comments: U <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 A <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +.EH13-241REV.I/A51 • 1 Q fJ(J001� <br /> EH 14-28 <br />