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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> (]� Telephone 12091 466-6781 <br /> y! PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> lI <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 /> Job Address i City Lot Size PM i <br /> E � ' <br /> Y <br /> w Owner's Name �ylyl Address Phone <br /> ContractorLa4ddessricense No. Phone ✓�d <br /> .TYPE OF WELL/PU P: �`I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR;❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I. <br /> a FO NDATION AGRICULTURE WELL . OTHER WELL PITS/SUMPS ' <br /> INTENDED USE ti , TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ""`­.—❑ Open Bottom_ _E].Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ci Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> _ f'] Public i f_I Other t Ia Delta Depth of Grout Seal Type of Grout _ + <br /> r I I Irrigation t OApprox. Depth I I Eastern Surface Seal installed by _ <br /> Repair Work Done ? ❑ Type of Pump H.P. State Work Done _ } <br /> f Well Destruction ❑ Weld Diameter Sealing Material(tep 505 <br /> Depth ' Filler Material (Beloi, <br /> i <br /> TYPE OF SEPTIC WORK:- NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> �! available within 200 feet1 <br /> Installation will serve: Residence_ Commercial. Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:. Water table depth <br /> SEPTIC TANK -❑ Type/Mfg- Capacity No. Compartments <br /> y PKG. TREATMENT PLT. ❑ � a r Method of Disposal <br /> Dstance-to nearest: Well Foundation / Pr pyrt .: ine <br /> LEACHING LINE 3 ❑ No. & Length of lines '� Total?ength/size <br /> 3 / i <br /> FILTER BED ❑ Distance to nearest: WellA oundation � Property Line <br /> SEEPAGE PITS 1'I Depth Size f Nurber <br /> SUMPS C Distance to nearest: Well dation Property Line <br /> DISPOSAL PONDS ❑ ��! '� <br /> I hereby certify that I have prepared this application and that the woirk will be done in accordantie 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."Contractors hiring or sub-contracting signature j <br /> certifies the following; ' cc ifyl`that in the performance of t4work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." II' i,, <br /> The applicant mu t call req "re Hsps is Complete dr ing on ere side. <br /> Signed, Title: Date: <br /> R DEPARTMENT USE ONLY } L <br /> r [_ O <br /> Application Accepted by Date � Area � <br /> Pit or Grout Inspection by Date Final Inspection by Date Z I <br /> Additional Comments: x , <br /> ❑.Stk 466-6781 ❑ Lodii1 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,•Silt., CA 95201 <br /> FEE K 11 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. I <br /> + EH 3-24 I (REV. i K5) <br /> EH 1+20 <br />