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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA l <br /> Telephone (209) 466-67$1 G <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. 1662 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. } <br /> Job Address City Lot Size PM <br /> { F <br /> Owner's Name Address It/ Phone�"L <br /> Contractor i Address f License No: Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEMA REPAIR 4e' OTHER Ll r <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 /> � <br /> 17 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcaJati,oa.i ...— Dia. of Well Casing <br /> W''Domestic/Private ❑ Gravel Pack El Tracy Type of Casing z Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth`of Grout Seal" Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern [--fSurface Seal Inst6lleF9y <br /> Repair Work Done Aer Type of Pump H.P., -° _-=�.St to Work pone <br /> Well Destruction ❑ Well Diameter �� V Sealing Material (top501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) �{� <br /> Installation will serve: Residence_ Commercial,_ OtherO <br /> Number of living units: Number of bedrooms j v� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC�TANK Q Type/Mfg, Capacity No. Compartments l <br /> PKG. TREATMENT PLT. a '��' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line a <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> %e_1t <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS. ❑ ;r <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 thdt 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."Contractors 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�� fy p p y persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st c II f"required inspections. Complete drawing on X&verse side. <br /> Signe� Title:_ & .sJ Date: <br /> r; <br /> Fn DEPARTMENT USE ONLY <br /> r >Application Accepted y Date G Area <br /> Pit or Grout Inspect! y Date ' Final Inspection by 1 f r `Dite .4^—L I—SC <br /> Additional Comments: m <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r ; <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,,tA 95201 <br /> < t <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE""„y fi -PERIVIVNO. <br /> + EH 13-24(REV.1/e5) 3�. Oji <br /> EH 13-26 v ki=101 ��s`r T6 6 <br />