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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ,� 7 19$9 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENVIRON <br /> Application is Hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here on 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� �Joaquin <br /> Local Health District. <br /> Job Address J 1� � City Lot Size PM <br /> OF <br /> Owner's Name Address - - - Phone <br /> Contractor s Address? License No:�-2—Phone A ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ J." SYSTEM REPAIR OTHER ❑ <br /> st_ .a�..fr,v <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERLINESDISPOSAL 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 /> �4,)omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ! I Irrit;anon Approx.;Depth l I.Eastern I.Surface Seal Installed by <br /> Repair Work Done $--Type of Pump�,Q H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 S <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION-I 1- DESTRUCTION l I (No septic system permitted if public sewer is <br /> ^"'6r'°, available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other + <br /> Number of-living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: - - Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �- <br /> PKG. TREATMENT PLT. ❑ ~" <br /> Method of Disposal. <br /> 6 <br /> �..,. ` s _ _ Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines - Total length/size <br /> FILTER BED ❑ Distance to nearest:- —Well -Foundation Property Line <br /> SEEPAGE PITS I I Depth 1 _ Size Number G <br /> t <br /> SUMPS Ll Distance to nearest, Well Foundation Property Line r, <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 /> rules and regulations of the San Joaquin Local Health Di-Wict. <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 <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." I <br /> The applicant ail for all required i pecti Complete drawing on r arse side. p <br /> Signed X Title: <br /> Date: <br /> OR DEPARTMENT USE ONLY i <br /> Application Accepted by Date <br /> _ <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Cl 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 /> - r <br /> FEE <br /> CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> r.EH 13-24(REV.t i n 51 / � <br /> EH 14-28 I <br />