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APPLICATION FOR PERMIT <br /> k SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.—JON AVE., STOCKTON, CA <br /> �i Telephone (209) 466-6781 <br /> ri <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED , <br /> (Complete in Triplicate) - L <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 /> n 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 /> i. Local Health District. / <br /> �/ S . r <br /> r <br /> Job Address CityLot Size PM <br /> Owner's NameAddress ��3' Phone <br /> ,����q !/�/J'Q/J Address • ` Phone <br /> Contractor License Na. _ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> l DISTANCETO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. 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 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 ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth . Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION. iNo septic system permitted if public sewer is <br /> 4f available within 200 feet.) <br /> Installation will serve: Residence_ Commercial,— Other <br /> j Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ T e/Mf <br /> � Yp 9 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> Y LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> E <br /> y SUMPS - ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 follow1g:- ertify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensation laws of CalifThe applicari r all required ' s. C rawing on reverse side. ` <br /> Signed Title: Date: <br /> F EPARTMENT USE ONLY <br /> bZ� Area <br /> ( Application Accept by Date � <br /> 4 -- c • <br /> Pit or Grout Ins�e y ate �/ Final Inspection by Date <br /> Additional Comments: __f�/� �G�� Y�'��" 7//��// <br /> ❑ Stk 466-6781 ❑ Lodi' 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> t Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O- Box 2009, Stk., CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> + EH 1324IREV.i/a5) - �, .' r <br /> r l <br /> p EH 1429 J S *•o � O N6 6-6 <br />