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' APPLICATION FOR PERMIT <br /> 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 /> I <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 /> - City OtLsize S~ <br /> Job Address <br /> AddressPh`one' <br /> Owner's Name �� <br /> Contracto ddressv� nse N y fi Phone <br /> TYPE OF WELL/PI MP: NEW WELL ❑ WELL REPLACEMENT'❑--DESTRUCTION <br /> ,r UMP�INSTAtLATION ❑ SYSTEM REPAIR ❑ OTHERµ❑ <br /> rw "` DISPOSAL FLD. PROP. LINE r <br /> DISTANCE TO P EAREST: SEPTIC�TANK�= SEWER LINES <br /> " N. , iAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> �` OUNDA7.kON _ <br /> INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial X❑ Open Bottom ❑'Manteca Dia. of Well Excavation Dia. of Well Casing <br />'I Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Type_of Grout <br /> ❑ Public ❑Other ❑ Delta Depth of Grout Seal <br /> rox. Depth' ❑=Eastern Surface Seal Installed by <br /> ❑ Irrigation _ APp. <br /> ftp. State Work D <br /> Repair Work Done 4 Type ump H.P. -- <br /> Well Destruction ell Diameter Sealing Material (top 50') <br /> Filler Material{Bei_ow 50`1 <br /> Depth. .. - <br /> TYPE OF SEPTIC WORK: NEVIIINSTALLATION ❑ IR ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is d <br /> available witfiin 24 fee-tk <br /> Installation will seve:IResidence commercial _ Other00, <br /> Number of living nits:• Number of bedroomsV� <br />' Water table�d'epth <br /> Character of soil„tofa depth of 3 feet: 0 '� <br /> ❑ TypelMfg Capacity No. Compartmen <br /> SEPTIC TANK ts <br /> PKC. TREATMENT P,LT. ❑ Method of D'i p sal <br /> t <br /> Distance to nearest: gwell Foundation Property Line <br /> ,.# <br /> LEACHING LINE� El No. length/size No. & Length of'lines � <br /> FILTER BED ❑ Distance to nearest <br /> ,.•r"`'` Foundation _ Property Line <br /> SEEPAGE PITS ❑ Dep Size •n��" Number <br /> SUMPS ❑ Distance to nearest: Wei.- ~Foundation Property Line <br /> DISPOSAL PONDS ❑ A. A <br /> ion and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 1 hereby certify that 1 have prepared this applicat <br /> rules and regulations of the San Joaquin Local Health District. <br /> Nome 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 perFonce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> 1 The applicant mus call for all required inspections. ate drawing on reverse side. <br /> 1 Date: <br /> Signed Title: <br /> FOR"DEPARTMENT USE ONLY � fLL� � � • "` <br /> Date { Area <br /> Application Accepted by <br /> Pit or Grout Inspection by '��Date Fines Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 L1 Manteca 823-7104 ❑ Tracy S�i�385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> 1 <br /> { t <br /> q <br /> FEE AMOUNT DUE AMOUNT REMITTED ' CASH RECEIVED BY DATE PERMIT"NO., . <br /> INFO <br /> 3 7- �7 <br /> + EK 13-24 iREV-,/651 . "�•/ —. - f <br /> .1 <br /> EH 142$ I <br />