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`t APPLICATION FOR PERMIT <br /> Ile- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1fi01 E. >1AZEL;1 ON,AVE , STOCKTON, CA <br /> • I Telephone(209) 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 /> Z.iO <br /> Job Address <br /> ear City Lot Size PM <br /> Owner's Name Address Phone <br /> I <br /> Contractor �� ress <br /> �a License No.1 Z3 3 _Phone p G <br /> TYPE OF WELL/PUMP: ;> NEW WELL E3WELL REPLACEMENT 71 DESTRUCTION El <br /> PUMP'INSTALLATION R--' SYSTEM REPAIR Q►— OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE t]F WELL.' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial LI Open Bottom 2 Ll Manteca Dia. of Well Excavation Dia. of Well Casing <br /> R,Vo'mestic/Private ❑ Gravel.Pack ' ❑ Tracy Type of Casing Specifications <br /> I I Public r 1 Other 1 7 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation -/ —..Approx. Depth 1 Eaytern SurSeal Installed by <br /> Repair Work Done {�' Type of Pump �� H.P. a State Work Done <br /> Well Destruction ❑ Well,Drameter Sealing Material (top 50'1 -- <br /> Depth J Filler Material (Below 501 - <br /> TYPE OF SEPTIC WORK: NEW INSTACLATION 1.1 R'E1'AIR/ADD,IT�ON l I . DESTRUCTION l 1 INo septic system permitted if public sewer is <br /> I 4 g tV ,, available within 200 feet.) A <br /> ,w r .� 1 I <br /> Installation will serve: Residence" <br /> esid nce`_/Commercial_ OtherA-: <br /> Number of living units: . Number of bedrooms. <br /> Character of soil to a depth of 3 feet: r Water table depth <br /> SEPTIC TANK ❑ Type/Mfg pacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ 'r Method of Disposal <br /> Distance to.neares : Well Faun tion Property Line <br /> c <br /> LEACHING LINE ❑ �No. &.Length of lin s Total length/size <br /> FILTER BED ❑ Distance to"nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 'Depth Siie _ Num <br /> SUMPS ❑ 'Distance to nearest: Well Foundation Property Line <br /> . f f <br /> DISPOSAL PONDS L] .� <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 lice ent's signature certifies the'folloriiing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any p on in such m ner as to becae subject to•workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> m <br /> i certifies th ollowing: "I certify at in the pert ante of a ark for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion law of Californi ." <br /> Thea licani must all regtiir i plate rowing on v 1 a.Title: <br /> EPA <br /> Date: <br /> I Signed <br /> r EPA NT USE ONLYy s _f ti <br /> Application Accepted-by Date F Area <br /> Pit <br /> — <br /> Pit or Grout Inspection by `"' � Dat ~"Final Inspection by � Da —7 f <br /> FT` <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 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 /> l FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY //� DATE Q PERMIT'ND. <br /> r.EH 13-24 iREV,t/851 W (r � I �k�y <br /> EH 14-26 <br />