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APPLICATION FOR PERMIT <br /> �jl I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED <br /> (Complete in Triplicate) { <br /> i 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 /> Application s y <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 —�j��b°l <br /> Job Address City T14R C Lot Size PM <br /> Phone <br /> Owner's <br /> Owner's Name 4. Address <br /> Phone <br /> TYPE <br /> - Contractor's Name -(�� License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .©,. <br /> DISTANCE TO NEAREST: SEPTIC TANK ?"""""SEWER-LINES _DISP_OSAL FLD. PROP. LINE <br /> FOUNDATION s AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Packs ❑ Tracy Type of Casing" Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ElType of Pump N.P. State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br />' Depth Filler Material (Below 501 <br /> I 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 If!f Commercial— Other i <br /> Number of living units: <br /> Number of bedrooms <br /> Character of soil to a depth f 3 feet: Water table depth <br /> SEPTIC TANK i C/Mfg { Capacity_( — No. Compartments <br /> k PKG. TREATMENT PLT. Fl �y , k � Method of Disposal Y <br /> Distance to nearest: Well 'f Foundation Property Line <br /> LEACHING LINE No. & Length of lines `- ' _jn ro I ength/siz " <br /> FILTER BED ❑ Distance to nearest:} Well f Foundation Property line .A r <br /> r Number <br /> SEEPAGE PITS ❑ Depth I Size t `_' <br /> SUMPS ❑ Distance to nearest:� Well a" Foundation Property Line <br /> -ter DISPOSAL PONDS ❑ <br /> 6I 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 /> .a`rules and regulations of the San Joaquin Local Health District. ,tet ' <br /> Home:owner or licensed agent's signature certifits-the following;.""l 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 thi_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 /> G The;appi€cant must call for allr uiretl r�pecbons. Complete drawing on reverse side. <br /> ,, I' <br /> h A,Signed X 11A <br /> [ Title: Date: <br /> F R DEPARTMENT USE ONLY � . <br /> Application Accepted by € / Date r Area <br /> kPit ar Grout Inspection by Date Final Inspection by Date �x��� , <br /> .,'Additional Comments: t <br /> El Stk 466-6781 ❑ Lodi 369 3fi21 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,PO. Box 2009 Stk., CA 95201 + <br /> FEE AMOUNT DUE AMOUNT REMITTED \.' ASHD"` ,*RECEIVED BYE \DATE r PERMIT NO. <br /> INFO _ <br /> � + EH 13-24(REV.10!63) 0 - '.r {J+N 'a�' - gs ,a-��J <br /> t EH 14-25 <br />