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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT V <br /> LAIV 1601 E. HAZE T ON AVE,, STOCKTON, CA <br /> Telephone (209) 466-6781 Iri <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 't,�, <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 /> !` <br /> Job Address ` City Lot Size pM <br /> Owner's Nam vL <br /> Address Phone <br /> Contractor Addres License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE l TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Q Manteca t Dia. of Well Excavation~ s <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications <br /> FI Public ❑ Other n Delta Depth of Grout Seal Type ofGrout <br /> I I Irrigation ---Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ ,Type of Pump H.P. State Work bone t <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (top 50') <br /> Depth Filler Material,(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I t DESTRUCTION lfJo septic system permitted if public sewerI� <br /> available within 200 feet.) ir <br /> Installation will serve: Residence-- Commercial— Other r Q <br /> Number of living units: ' Number of bedrooms i <br /> Character of soil to a depth of 3 feet: '– <br /> Water table depth, <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments l <br /> PKG. TREATMENT PLT. ❑ ,Method of Disposal <br /> y <br /> Distance to n earest: Well Foundation Property Line d o <br /> LEACHING LINE ❑ No. & Lehgth of lines Tota! length/size <br /> FILTER BED ❑ Distance io,nearest: Well FoundationProperty Line{ <br /> t� <br /> SEEPAGE PITS F l I Depth Size Number E' <br /> SUMPS L� Distance to nearest: Well Foundation <br /> Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I haveprepared this application and that the work l <br /> will be done in accordance with San Joaquin county ordinances, state caws <br /> rules and regulations of the San Joaquin Local Health District. , . <br /> Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shal of <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting sign ure 4 <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 compe a--- <br /> tion laws of California." <br /> / The appliA A-7 <br /> cant st call f all re uired ctions. Complete drawing on reverse side. 4 <br /> Signed X Title: <br /> Date; <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by r <br /> Date Area <br /> Pit or Grout Inspection DateFinal Inspection by 1 <br /> Date <br /> r <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 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 AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED 8Y DATE PERMIT'NO. <br /> � � <br /> + EH 1321 IRE'V. /Hsl f C� <br /> ... EH 14-26 S � F <br />