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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTFrttCT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ' PERMIT EXPIRES TYEAR 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 /> f 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 City S,A Lot Size PM <br /> Dwner's,Name Address Phone <br /> �V. Contractor Address License No. Phone <br /> / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,; f 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 Wel! Excavation Dia. of Wel! Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> fl Public ❑ Other ❑ Delta Depth of Grout Sea! Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern F_-. Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Wel! Diameter Sealing Material )top 501 <br /> Depth Filler Material (Below 50') {�� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTIOINo septic system permitted if public sewer is tRs <br /> i available within 200 feet.! <br /> Installation will serve: Residence_ Commercial_ Other �t. <br /> Number of living units: Number of bedrooms <br /> i Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments b" <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to neatest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS f I Depth. Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> i 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 Di§trict. E <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 must call for'all-required-ir' pectlons. Complete drawing on reverse side. <br /> � <br /> vim[' Signed X FYI w T T Title:y nu) 1..1- Date: <br /> F DEPARTfNENT USE ONLY <br /> Application Accepted byDate 1 ~� ea <br /> Pit or Grout Inspection by Date Final Inspection by i Date <br /> Additional Comments: "26 r<�« IG <br /> ca- <br /> ❑ Stk 466-6781 Lodi 369-362V ❑ Manteca -7104 ❑ Tracy 835-6385 s t <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTb3 CCA H RECEIVED BY DATE PERMIT-NO. <br /> +.EH13-24IREV,1/851 .. �� /�- ks-ns-* <br /> Ei <br /> ll 14-26 <br />