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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ( � 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> t Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> AppJoaquin Local Health District for a <br /> made intion is compl coreby made to the mpliance with San Joaquin nCounty Ordinance No.549 for sewage or No. 1862 forit to ct and/or well/pump install <br /> the the Rules herein described.This application <br /> Local Health District. and Regulations of the SJoaquin <br /> Job Address ® a <br /> City Lot Size � PM <br /> Owner's Name <br /> Address -r i �f-p <br /> Phone � �+ <br /> Contractor <br /> ess License No. <br /> TYPE OF WELL/PUMP:1' NEW WELL ❑ Phone <br /> WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE OTHER WELL PITS/SUMPS \� <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom -- � <br /> ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> ❑ Public ❑ Tracy Type of Casing <br /> ❑ Other ❑ Delta Depth of Grout Seal Specifications <br /> ❑ Irrigation --Approx. Depth ❑ EasternType of Grout <br /> Repair Work Done ❑ Type of Pump H. Surface Seal Installed by <br /> Seal State Work Done <br /> Well Destruction <br /> ❑ Well Diameter Sealing Material (top 50') <br /> Depth <br /> Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INS'TAL�LATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Y <br /> Installation will serve: Residence Commercial_ available within 200 feet.) <br /> Number of living Other <br /> units:� Number of bedrooms i^ <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Distance to nearest: Well a pMethod of Disposal <br /> Foundation _ property Line _ <br /> LEACHING LINE ❑ No. & Length of lines C <br /> FILTER BED El Distance to nearest: Well 1�� _ T tai length/size d <br /> Foundation_ property Line <br /> SEEPAGE PITS ❑ Depth ` s <br /> SUMPS Size Number <br /> ❑ Distance to nearest: Well J i L— a0 <br /> DISPOSAL PONDS ❑ Foundation Property Line <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 <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 not <br /> tion laws of California." permit is issued,I shall employ persons subject to workman's com <br /> The applicant m c pensa- <br /> r all requ' pections. Comp a awingon r rse side. <br /> Signed <br /> Title: / <br /> Date. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted bye, i <br /> � � yy Date Area , <br /> Pit or Grout Inspection by � a / -� r^ tk <br /> 41 <br /> Date '/Final Inspection by ; <br /> Additional Comments: Date <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 <br /> 6385 <br /> Applicant- Return all copies to: Environmental He❑altthaPe mit/823-7104 <br /> �i��1601 E❑Hazekon AvTracy e., P.O. Box 2009 Stk., CA 96201 <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED CK <br /> RECEIVED BY <br /> + EH 13-24CASH DATE PERMIT'N0. <br /> ?A(REV.ties) �� � <br /> EH 1426 � � // <br />