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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 <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 City of Size PM <br /> Owner's Name r 1 Address Phone <br /> s <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP:_. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUC <br /> P M LLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK `'� SEWER LINES DISP FLD. PROP. LINE <br /> FOUNDATION A LTURE WELL HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO N SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ell Excav Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications <br /> FI Public ❑ Other ❑ Depth of Grout Seal a of Grout--------. _ <br /> I I Irrigation �.Approx. t I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Ty ump H.P. State Work Done <br /> Well Destructi Well Diameter Sealing Material (top 50') d <br /> Depth Filler Material (Below 501 —_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION t I DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <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 /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line C' <br /> 70 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 performance 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 all for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: 6 (4-2 A-14 Date: +. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by t Date Area <br /> Pit or Grout Inspection by ate Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> K RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.t/H 5) it 3��"" �/ C 7-_-74 <br /> EH 14-26 111 <br />