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'APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA t`s <br /> Telephone {209} 466.6781, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE J� <br /> {Com I N c? <br /> p ete in Triplicate} Q <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. is 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:r— ^ ` <br /> ob Address <br /> /�� Lot Size PM <br /> �wer'snName dress Phon <br /> Contractor Address <br /> ' License No. Phone <br /> TYPE:OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> " .:. ,,T,•."` 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 <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private El Gravel Pack 11 Tracy TypDia. of Well Casing <br /> ElIndustrial <br /> of Casing <br /> El Public Ll Other .f Specifications <br /> a, El Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation _!Appro`. Depth 1-1EasternSurface Seal Installed by <br /> Repair Work Done ElType'gf'Pump H.P. ` n <br /> State Work Done yl'\ <br /> Well Destruction ❑ Well'Diameter Sealing Material ftop 50'I h <br /> Depth I Filler Material (Below 501 v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION/V {No septic system 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 fe4;. <br /> SEPTIC TANK ❑ T Water table depth <br /> ype/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. L2i ) <br /> Method of Disposal <br /> Distance:to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines r <br /> Total length/size <br /> FILTER SO ❑ Distance to nearest: Well "` Foundation <br /> � Property Line <br /> SEEPAGE PITS ❑ Depth Size t <br /> Number <br /> .SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS El ° Property Line <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 tobecomesubject 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 <br /> tion laws of California." permit is issued, I shall employ persons subject to workman's compensa- <br /> The applicant call for all required:inspections:Complete drawing o verse side. ' <br /> Si ned �I <br /> g Title ate: <br /> FOR T USE ONLY <br /> I Application Accepted by _ <br /> Date Area Q <br /> Pit or Grout Inspection by Date Final Ins <br /> 7 pection by Date ! <br /> Additional Comments. <br /> El Stk 466-6781 r-1Lodi_ 369-3621 ❑ Manteca 823-7104 ❑ racy <br /> Applicant Return all copies to: Environs ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO + CASH RECEIVED$Y DATE PERMIT'NO. <br /> + EH 13.241REV.1/a 51 <br /> EH 14-28 t S =+ <br />