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Y APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � � x <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (2091 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED �'`- <br /> (Complete in Triplicate? ENWROMENTAL. HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install the 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 ft's <br /> San Joaquin <br /> Local Health District. <br /> Job Address 1/ '- a City 7/tI-4v Lot Size PM <br /> Owner's Name <br /> i <br /> Address Phone + <br /> Contractord Address <!/ L.icense No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> " PUMP INSTALLATION ❑ SYSTEM REPAIR 9Y— OTHER ❑ <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 SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public 17 Other 1 Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _..Approxi;Dept l I Eastern Surface Seal Installed by Xas <br /> Repair Work Done ❑ Type of Pump H.P. - State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material [top 50'1 <br /> Depth I Filler Material IBalow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l 1 INo septic system permitted if public sewers <br /> available within 200 feet.) <br /> Installation will serve: Residence_ry Commercial _ Other <br /> _, t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: i Water table depth fti <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> _ I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth SizeNumberCl <br /> SUMPS L-1Distance to nearest: Well Foundation Property Line t <br /> .DISPOSAL PONDS ❑ """� .:i x. z ' <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." Contractor's hiring or sub-contracting signature y4 <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 /> 4 <br /> The applicant mus all for all req''r Ipspections. mplete drawing on reverse side. } <br /> Signed Title: �.'a7/�ef� �f1�,�Q Date: <br /> t_ ZQ 4 <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by 4! Date Final Inspection by Date <br /> Additional Comments: 1 <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.1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.' <br /> CK <br /> INFO <br /> ♦.EH13-24 IREV. <br /> EH 14-26 --✓ I <br /> p <br />