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k <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT =' <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> .r (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 H compliance with San Joaquin C u my 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 /> r . <br /> (J f <br /> Job.Address <br /> J l j City G Lot Size, PM <br /> J� Owner's Name Address <br /> Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP- License No. Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> a PUMP INSTALEl❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LiNES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation <br /> LJ LlGravel Pack Dia. of Well Casing <br /> ❑ Tracy -Type of Casing <br /> ❑ Public ❑ OtherSpecifications <br /> ❑ Delta � Depth of Grout Seal <br /> IN <br /> ❑ Irrigation _q Type of'Grout <br /> pprox. Depth ❑ Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump I H.P. <br /> Well Destruction ❑ Well Diameter I State Work Done <br /> Sealing Material (top 50') <br /> Depth I Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> Installation will serve: Residence�i�Commercial_ Other available within 200 feet.) <br /> H <br /> Number of living units: Number.of bedrooms, <br /> Character of soil to a depth of 3 feet: <br /> #� 4 y Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ + <br /> Method of Disposal <br /> Distance tolarest: Well Foundation <br /> I Property Line <br /> LEACHING LINE ❑ No. & Length of lines N <br /> i Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation i <br /> Property Line <br /> i <br /> SEEPAGE PITS ❑ Depth ` Size i <br /> SUMPSt <br /> ❑ Distance to nearest: Well Foundation <br /> Number <br /> on <br /> DISPOSAL PONDS ❑ - _ ___ _ Property Line <br /> i <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. s <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 applicant must call for allquired-in ctions. Complete drawing on reverse side. <br /> X Signed Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by P <br /> Date 3_( ®� V <br /> Area <br /> Pit or Grout Inspecti y <br /> Data <br /> Final Inspection by Date <br /> Additional Comments;/ <br /> ❑ Stk 466-6781 ❑ Lodi 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 r AMOUNT REMITTED CK <br /> INFO i; CASH RECEIVED BY DATE PERMiT'NO. <br /> + EH 13-24(REV.1/0 s) <br /> EH 1428 S <br /> l <br /> b FS7 <br />