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APPLICATION FOR PERMIT 5-5 t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> l.� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> II (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 welupump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> W <br /> Job Address City _ Lot Size PM <br /> �a <br /> Owner's NameAddressPhone <br /> s <br /> Contractor Address } 6 f "icense No. Phone <br /> "TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 Excavation Dia. of Well Casing ± <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing t Specifications <br /> 1-1 Public f F1 Other F.1 Delta Depth of Grout Seal j Type of Grout <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ r <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> E <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') : 4 <br /> Depth Filler Material IBelow 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is <br /> 4 I <br /> vailable within 200 feet.) <br /> Installation will serve: Re idence Commercial_ Other <br /> Number of living units: 77 Number of bedrooms <br /> r <br /> Characfer of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity I No. Compartments , <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal' <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines _ Total length/size I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> .i <br /> SEEPAGE PITS I 1 Depth Size Number C <br /> SUMPS ❑ Distance to nearest: Well Foundation . Property Line <br /> DISPOSAL PONDS U <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 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 perfor nce 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 inspec to Complete drawing on reverse side. <br /> �Sign4"C� <br /> ed , i Title: � Date: ll�. <br /> FOR DEPARTMENT USE ONLY l <br /> Application Accepted by Date Area I` J <br /> Pit or Grout Inspection byDate Final Inspection byj��l Date <br /> � �( <br /> Additional Comments: �e '1 <br /> ❑ Stk 466-6781 O Lodi -?369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to:II Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> A <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. <br /> ..EH 13-24 IREV.F i H slif <br /> EH 14.26 <br /> n - <br /> , e <br />