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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA , <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> is <br /> cation is <br /> madec compliancentlwith Sanade toJoaqu nthe San CouJoanty Ordinance Nuin Local o,549 for sewage or h District for a permit <br /> 1862 for construct and/or <br /> and the Rules and herein <br /> gulations of tlhe San'Joaquin <br /> Local Health District. <br /> Job Address <br /> anC City of Size <br /> _ <br /> Owner's Name Address r hone <br /> License Lise No <br /> � Address �i( Phone_ , <br /> Contractor _-._ _ <br /> L REPCACEMENT El <br /> TYPE OF WELL% UMP: NEW WELL, WELSYSTEM REPAIR ❑ DESTR TIOIV ❑ <br /> PUMP INSTALLATION a❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> t ! FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> I <br /> UNDED <br /> IN USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l <br /> ❑ pomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications € <br /> ` h --Y--» Type of Grout — <br /> l"1 Public l-1 Other ❑ Delta Depth of Grout Seal <br /> 1 I Irrigation f�""Approx. Depth l l Eastern Su11 ce Seal Installed by <br /> Repair Work Done ❑ ',',Type`of Pump H.P. State Work Done <br /> Sealing Material Ito 50'1 <br /> Well Destruction � ❑ �.Well'Diameter 9- p <br /> Dep[h Filler Material (Below_5Tj <br /> -;TYPE OF SEPTIC WORK: NEW�INSTALLATION REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is <br /> K: ! available within 200 feet.) <br /> Installation will serve: F Residence Commercial Other <br /> .; Number of living units: Number of bedroom <br /> w e 3 Water table depth <br /> Character of soil,to a iiepth of feet. <br /> SEPTIC TANK TypelM4g RA�C Capacity j(No. Compartments <br /> X""" ' ° Method of Disposal <br /> µPKG. TREATMENT PLT. ❑ f <br /> t r Distance to nearest: Wel! Foundation—,Property Line . <br /> „7 _ ms's <br /> LEACHING LINE � Na. & Length of lines ,.Y.�.— ��, Total lengthlsize <br /> FILTER 'BED "' —ED—Distance to nearest: '-Y--'Well " ^" Foundation �"=Property+ine-- <br /> Number <br /> SEEPAGE PITS .Depth —p��. _Size_. f i <br /> r-SUMPS L❑ Distance to nearest: Well� Foundation Property Line <br /> � � .- <br /> '�-,DiSPOSAL PONDS ❑ <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 /> a istrict. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this <br /> rules and regulations of the San Joaquin Local Health Dpermit is issued, I shalt lot <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 xhat in the performance of the work for which th�permit is issued,k Bhall employ persons subject toeworkman's campen - <br /> tion laws of California." <br /> i Aa,: } ` <br /> i I The applicant mus all Jai all re ired�ins tions. Complete drawing on teverse side <br /> Signed X � Title: Date: <br /> � r <br /> FOR DEPARTMENT USE ONLY r � <br /> f t � `• <br /> Application Accepted by Pate- Area <br /> Pit or Grout Inspection by <br /> Date � Final Inspection by <br /> Additional Comments: <br /> ❑_Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> a FEE AMOUNT DUE AMOUNT REMITTED CASH CK S RECEIVED BY DATE PERMIT NO. <br /> +-EH13.241REV.I RSiINFO <br /> EH 14-2b <br />