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ti APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> r Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> n P (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 wlth 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.'- k ' y <br /> Jab Address ' Cityr'�Lot Size PM <br /> a"-, <br /> ` Address Phone <br /> Owner's Name _ 11 <br /> Contractor Address_-- -`- —- License No. Q9Phone <br /> TYPE OF WELLIPUMPi NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> k _ I PUMP INSTALLATION ❑.k SYSTEM REPAIR ElOTHER El <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />} FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION_SPECIFI_ CATIONS <br /> I ❑ Industrial ❑ Open Bottom" ❑ Manteca'"� Dia.-df-Well Excavation ` Dia. of Well Casing <br /> 7 Domestic/Private ❑ Gravel Pack ❑ Tracy _ Type of Casing .�. Specifications <br /> ❑ Public 7 Other ❑Delta • A Depth of Grout Seal ' ' Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern I Surface Seal installed by <br /> F Repair Work Done ❑ Type of Pump . 4 t State Work Done / <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> 11 <br /> Depth ­—Filler-Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION [D DESTRUCTION is system permitted if public sewer is . <br /> f. ! available within 200 feet.) L j <br /> Installation will serve: Residence Commercial Other i <br /> Number of living units: -1 Number of bedrooms <br /> Character of soil to'a'depth o 3 feet: Water table depth <br /> I SEPTIC TANK `lt� pe/Mfg C nts Q Capacity No. Compartments <br /> PKG. TREATMENT PLT. El Method of Disposal <br /> ` Distance to nearest: Well Foundation r Property Line <br /> LEACHING LINE ❑ No. &;Length of lines Total length/size j <br /> 5 <br /> FILTER BED ElDistance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS ❑ Depth. Size Number <br /> I SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> -DISPOSAL PONDS 11 1 <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 /> rulesIand regulations of the San Joaquin Local Health District. I = l..f* , . <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fdr which this permit is issued, I shall not <br /> emp rZ ny person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or subcontracting signature <br /> s certified th ollowing: " rtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> -" <br /> tion laws of, ifornia.' i <br /> 3 , <br /> T applica t rr1 all fora req 'red in ction C plate drawing o averse�id r <br /> r- <br /> fffr <br /> Title: Date. T <br /> Signe .. <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date 2 Area ztp <br /> L Pit or Grout Inspection by Date Final Inspection by r Dated l 1 � <br /> r Additional Comments `�_=�.�Y�. • <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + 4 <br /> + EH 13-21(REV.1/a 5) <br /> EH 1428 <br />