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APPLICATION FOR PERMIT <br /> # SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA DOT 2 I�t3p <br /> � <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PEIRW!11'1'ti2ViCES <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 /�=�-� ��'-y rte{ City Lot Size PM <br /> Owner's Name Address d Phone <br /> Conlraco2C!!, Address 6 L��se No.,!�a Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT- ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR'D OTHER ❑ - <br /> DISTANCE TO NEAREST: SEPTIC TANK ,SEWER LINES DISPOSAL FLD. PROP. LINE <br />,F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial f "❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (.Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _._Approxi Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump .O� H.PState Work Done <br /> Well Destruction ❑ Well Diameter �-- Sealing Material (top 501 <br /> .Depth 18!?� Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: 'Residence T 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 <br /> I M. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line <br /> f <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 Locai lie'46 Di1irict: - = — -T ­_ <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 mariner 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 mu II required inspections. Complete drawing on r rse side. <br /> Signed X - Title: t Date: <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by " Date { Area <br /> 1 <br /> Pit or Grout Inspection byj f Date 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 CK RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13.21(REV.r/n5) <br /> EH 14-26 '�1,1,I_ <br /> T,ij'3 <br />