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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 <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 /> Job Address City of Size Iro PM <br /> Owner's Nam Address Phone � <br /> Contract v Address License N e7 JZ.. Phone G <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ HER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES DI FLD. PROP. LINE <br /> FOUNDATION AGR LTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS <br /> i <br /> ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ c Type of n <br /> Y YP 9 Specifications <br /> ❑ Public N Other El Delta Depth of Grou eal Type of Grout <br /> I 1 Irrigation __.-Approx. l I Eastern Surface Sea! Install by <br /> Repair Work Done ❑ Type of Pump H.P. tate Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) Uq <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 k;Capacity L No. Compartments <br /> PKG. TREATMENT PLT. El �* Method ofof"pisposal ] <br /> Distance to nearest: Well Foundation Property Line /� <br /> F <br /> LEACHING LINE 0 No. & Length of lines ° Total length/size - �J <br /> n <br /> FILTER BED ElDistance to nearest: Well Foundation Property Line _bY� <br /> (� <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS D Distance to nearest: Well ~Foundation Property Line t <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 .A <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 <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." C <br /> The appii t u all fo a ired ns ctioA. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> r" FOR DEPARTMENT USE ONLY Q <br /> Application Accepted by Date 3--t3 Area <br /> �` <br /> Pit or Grout Inspection by � Date Final Inspection by!P <br /> Additional Comments: S_ <br /> L7 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 INFO AMOUNT DUE AMOUNT REMITTED GK It SH RECEIVED BY DATE PERMIT'NO. <br /> +,EH 13-24(flt:V.1/N 5) �� <br /> EH 11-28 <br />