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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED n <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. - %1\ 1. <br /> -Z <br /> Job <br /> %1\Job Address City Lot Size PM <br /> Owner's.Name, Address � Phone a <br /> i <br /> a fig- l <br /> Contractor's Name t^ license No. Phone <br /> ,�' <br /> TYPE OF WELL/PUMP: r,.r- -- -NEW WELL L1_ WELL REPLACEMENT C1 DESTRUCTION ❑ - - — -� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATiONt` AGRICULTURE WELL OTHER WELL—;PITS/SUMP$ <br /> INTENDED USE TYPE OF WELL-h"� PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ' ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack444"'F" ❑ Tracy Type of Casing ""' Specifications <br /> Ll Public ❑ Other E ❑ Delta Depth of Grout Seal 0. _"Type of Grout r <br /> ❑ Irrigation _- Approxi Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of*,Pump <br /> � H;P. State Work Done S <br /> Well Destruction ❑ Well Diameter,i Sealing Material {top 501 J <br /> Depth I Filler,,Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTAL. ON" REPAIR/ADDITION ❑ DESTRUCTION ❑ Wo septic system permitted if public sewer is <br /> `*: <br /> � .z=.: available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other. <br /> ice C <br /> Number of living units: Number of bedroon}s i L <br /> Character of soil to a depth of 3 feet: %nCit ' oS0� Water table depth <br /> SEPTIC TANK Yf Type/Mfg. Capacity- - No.Compartments, <br /> PKG. TREATMENT PLT. ❑ A K,,s �- f - Method of-Disp <br /> Jal <br /> - D <br /> Distance to nearest: Well I�1 n Foundation Property Line�j� <br /> LEACHING LINEy,..b_,_Br. ,No. &,Length of fines_ T��length/size l <br /> FILTER BED ❑ Distance to'nearest: Well• l l t5 Foundation__ Property Line <br /> SEEPAGE PITS ❑ Depth ' Size 1 I Number 1 <br /> SUMPS ❑ Distance to nearest: Weil: Foundation Property f Line..- - <br /> DISPOSAL PONDS L1 `` <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 />{ ompensation laws of California."Contractor s hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's c <br /> f certifies the following:.:a.certify-that in the-performance-of the-wbrk'fdrwhich"this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The <br /> I The applicant must call for all required 'inspections. Complete drawing on reverse side. <br /> f <br /> Signed Title: Date:` <br /> ' FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> PR y or Grout Inspection bDate Final Inspection b y Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 36.43621 ❑ Manteca 82:3-7104 ❑ 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 CASH RECEIVED BY DATE PERMIT`NO. <br /> INFO <br /> + EH 1324(REV.10183} - S5 :�7 <br /> EH 14-26 Q <br />