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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 1�'1. 1 �-D <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 ll� City��11' .U' Lot Size PM <br /> Owner's Name Address 0 � "�`� Lj/7 q <br /> C� Phone — <br /> Contractor's Nam License No. 4 r� (P Phone #0 S <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL - OTHER WELT 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 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ElDESTRUCTION F) iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will'serve: Residence v Commercial_ Other <br /> Number of living units� -Number of r oms <br /> Character of'soil to a deptli•of 3 feet: Water table depth 60 <br /> SEPTIC TANK CY Type/Mfg Capacity � No. Compartments IQ <br /> PKG. TREATMENT PLT. ❑ --- — � r � r Method of Di O�sal <br /> 0 <br /> Distance to nearest: Well—a Foundation 1 d Property Line r <br /> LEACHING LINE 2-�No. & Length of lines - `l 0 Total length/size X (� <br /> FILTER BED ❑ Distance to nearest: ­.Well t,Q' Foundation , ,� f <br /> .l�.L_ Property Line <br /> SEEPAGE PITS. 2T' Depth Size Number IS _{ { <br /> SUMPS ❑ Distance to nearest: Well 1 SO' Foundation—[, Property Lihe- �� l <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 applica t must call all equired inspections. Complete drawing on reverse ide. <br /> Signed Title: k Date: <br /> } <br /> FO DEPARTMENT USE ONLY ia Application Accepted by DateArea <br /> Pit or Grout Inspection by 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.D. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> + EH1}24/REV-10!836 _7o, <,. <br /> ice` <br /> EH 14-28 Q C5 p / 1 Z� <br />