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APPLICATION FOR PERMIT <br /> to SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 'E. HAZEL T ON 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 /> ` 3� 1 <br /> Job Address �`' O PM <br /> Citya�ot Size <br /> Owner's Name J Address Phone 3" a <br /> f <br /> Contractor Address License No. Phone 1 <br /> TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' <br /> ❑ Industrial -❑ Open Bottom" - ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material(top 501 <br /> Depth Filler Material Melow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is <br /> 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: 14 ' Water table depth <br /> SEPTIC TANK Type/Mfg f Capacity No. Compartments i <br /> PKG. TREATMENT PLT. ❑ �„ Method of Disposal <br /> r 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 ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 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."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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must II for all required 'nspections. Complete drawing on reverse side. <br /> Signed �� Title: Date: <br /> {l�A11 FOR DEPARTMENT USE ONLY <br /> Application Accepted by ` +t Date ` 0— Area J <br /> Pit or Grout Inspection b Date Final Inspection by Date <br /> Additional Comments: G� 7 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -71 ❑ TrW 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CAS K H RECEIVED BY DATE PERmrrNO. <br /> +EH13-24(REV.1/857 <br /> EH 14-23 ((( v <br />