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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 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 / /1 dge City Lot Size <br /> PM <br /> Owner's Name - gddress Phon��� d <br /> Contractor f{ Address r <br /> License N / Phone \ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINT= <br /> FOUNDATION AGRICULTURE WELL .OTHER-WELL PITS/SUMPS h <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �\ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation11 <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> E] Irri Irrigation Type of Grout I <br /> g --Approx. ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.p <br /> State Work Done w <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50.1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTlO (No stem septic system Y permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well <br /> Method of Disposal <br /> Foundation property Line <br /> 10 <br /> LEACHING LINE- ❑ No. & Length of lines 1' " <br /> Total length/size- <br /> FILTER BED ❑ Distance to nearest: Weil Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth SizeNumber <br /> SUMPS El 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." Contractors 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 t call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date � <br /> Area <br /> Pit or Grout Inspection by Date — .Final.} s <br /> pectiorr by- Data� <br /> Additional Comments: 1 �6)2_LL ���f `y� IS <br /> Ll Stk 466-6781 CJLodi 369.3621 ❑ Mante 823-7104 11 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 <br /> INFO CK H RECEIVED BY DATE PERMIT ND. <br /> + EH 1428-24(REV,t i e 5) 3� .a� <br /> EH 14 �S'o a � -7 (k- `. � .7 ,j <br />