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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) <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 weld/pump and the Rules and Regulations of the Sa 'u <br /> Local Health District. r� _ in <br /> cX <br /> �� <br /> ! ' City Lot Size <br /> PM <br /> Job Address <br /> Address 6-w Phone _ <br /> Owner's Name-��' ' 1 ' <br /> Contra f. a Address . ,ze License No. �� � -Phone• '�_S/�S._ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> L3 Domestic/Private El Gravel Pack LD Tracy yp g T of Grout <br /> ❑ Public Ll Other F-1DeltaDepth of Grout Seal Type <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 7 REPAIR/ADDITION ❑ DESTRUCTION❑ (Noseptic system <br /> m rmiit;ed if public sewer is <br /> availabInstallation will serve: Residence. ✓ Commercial Other f <br /> Number of living units: Number of e room <br /> Character of soil to a depth of 3 feet: ,. <br /> Water table depth <br /> SEPTIC TANK Type/Mfg -capacity &Q No. Compartments <br /> PKG. TREATMENT PLT. ❑ ( Method of <br /> Disposal <br /> Distance to nearest: welly Foundwion Q.— PropertLine y2 <br /> Total length/size <br /> LEACHING LINE l� No. & Length of lines � �"� � r i <br /> ..._ Property Line <br /> FILTER BED El Distance to nearest: Well 160 Foundation Foundation P rtY <br /> r <br /> SEEPAGE PITS [Zrl Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well � _ Foundation Property Line <br /> 7:5— <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 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 parson in such manner-as to 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." r <br /> The app]=]" <br /> pections. Complete drawing on reverse 'de. <br /> Signed <br /> y � - Title: � Date: <br /> FOR DEPARTMENT USE ONLY r� <br /> Date ` Area <br /> ApplicaPit or G <br /> 7. Date If final inspection by Data <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 CK RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTEQ CASH <br /> INFO f �j�1r <br /> +EH 13-24.INEV.1/851 Y>r/11F•bf� C? `,7'1 <br /> I <br /> EH 14-20 C` o <br />