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(A.r— APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. HAZE T ON AVE., STOCKTON, CA <br /> F mn , Telephone (209) 466-6781 r <br /> ► PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Tj1✓ v t <br /> (Complete in Triplicate) <br /> District for a permit to construct and/or install the work herein described. This a licati ui� <br /> Application is hereby made to the San Joaquin Local Health 549fo p p <br /> made in compliance with San Joaquin County Ordinance Na.549 for sewage or No. 1862 for weNlpump and the Rules and Regulations of the San oaq 11 <br /> Local Health District. t <br /> City Lot Size PM <br /> Phone <br /> Job Address <br /> Owner's Name <br /> dr <br /> Address License No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ID DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing SQecifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp Type of Grout <br /> i`l Public <br /> n Other ❑ Delta Depth of Grout Seal yp <br /> I 1 Irrigation —_Approx. Depth 1 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done _ Y <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION l i DESTRUCTION I I availabNo le4wit within feet.) if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: 4 Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK El Type/Mfg <br /> Capacity_L. No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> III LEACHING LINE No. & Length of lines T-- <br /> �otallength/size l <br /> FILTER BED ❑ Distance to nearest: Well In Foundation��- Property Line <br /> De th Size — �-- umber <br /> SEEPAGE PITS � P v ..v <br /> SUMPS `,. Ll Distance to nearest: Well Foundation. — ProPertY Line — <br /> DISPOSAL'PONDS ❑ <br /> f 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 /> to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in such manner n <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 compansa <br /> tion laws of California." <br /> The applicant must call for all required inspections.-Complete drawing on re rse side. <br /> b Date: <br /> Signed X e' <br /> FOR DEPARTMENT USE O LY Q <br /> ce <br /> Application Accepted by Date Area <br /> ' Pit or Grout inspection by <br /> Date Final Inspection by – Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369 3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 4: <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAti95201 <br /> FEE GK RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13-24 4REv.r i n 5) <br /> EH 14-26 <br />