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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 TYEAR FROM DATE ISSUED <br /> I <br /> (Complete in Triplicate) I <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� / / 4Z&V _n- y Lot Size PM <br /> Owner's NameAddress . _ Phone <br /> , ; �� �- /. <br /> Contractor Addres �Zl License P <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 Excava Dia. of Well Casing _ <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T i asing Specifications <br /> ❑ Public ❑ Other 1 f� Delta Depth of-Grout Seal_ Type of Grout _ <br /> I I Irrigation —_Approx. Depth astern Surface Seal Installed by <br /> Repair Work Done EI Type of H,P.. State Work Done' I° <br /> Well Destruction ❑ Diameter Sealing`Nlatenal Itop 50') \ <br /> Depth Filler Material (Below 501 <br /> TYPE OT SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION• o 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. ❑ _ r Method of Disposal <br /> Distance to nearest: Well 'FounAation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well.__. Foundation,.. Property Line <br /> SEEPAGE PITS I I Depth Size Number i <br /> SUMPS Ll 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. ' `J <br /> Home owner or licensed agent's signature certifies the following':"I certifydthat.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 applica ust call for all required inspections. Complete drawing onje <br /> rse3de- — <br /> ' <br /> Date: <br /> Ttle b � v <br /> FOR DEPARTMENT USE ONLY l <br /> Application Accepted by Date f r � Area r <br /> Pit or Grout Inspection by Date Final Inspection by OVADates <br /> Additional Comments: <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 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH <br /> RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.i/A 5) �J '� ;?/L <br /> EH 14.26 - <br />