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4L APPLICATION FOR PERMIT W ; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> s Telephone 1209) 466-6781 _ ) ,,; <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � "' Y•Gti �+" <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. 5491or sewage or No. 1862 for well/pump and the Rules and Regulations of the Sari Joaquin <br /> Local Health District. <br /> { <br /> Job Address g City Lot Size PM r <br /> _ 1 <br /> Owner's Name Address Pho e <br /> Contractor . Address :Licens Pho <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI PROP. LINE <br /> FOUNDATION AGRICULTURE WEL OTHER WELL PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM A ONSTRUCTION SPECIFICATIONS' " .1. <br /> ❑ Industrial ❑ Open'Bottom ❑ eca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1r <br /> f i Public l-1 Othe' C1 Delta Depth of Grout Seal Type of Groin <br /> I I Irrigation Approx. Depth l 1 Eastern Surface Seal Installed by e f <br /> Repair Work Don Type of Pump: H.P. State Work Done <br /> i <br /> Well Destr n {❑ Well Diameter Sealing Material itop 501 <br /> Depth Filler Material (Below 5011 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION Ll DESTRUCTIO Wo septic system permitted if public'sewer is <br /> available within 200 feet.) I. <br /> Installation will serve: Residence'— Commercial— .Other t '+ <br /> Number of living units: Number of bedroomsk <br /> Character of soil to a depth of 3 feet: Water table depth <br /> k <br /> SEPTIC TANK LJTypelMfg Capacity No. Compartments k <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t Distance to nearest:--"Well-�'"'-�" F(yilndation 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 1 Depth Size �4's + , Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line r <br /> DISPOSAL PONDS ❑ 1 <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\andC <br /> rules and regulations of the San Joaquin Local Health District. i <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 na <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." <br /> The applica must call for all requ d 'nspec igns. Complete drawing on reverse side. ) <br /> .Signed,X Title: _ Date: 1 <br /> W OR DEPARTMENT USE ONLYT i <br /> Application Accepted by Date Area_ `l <br /> Pit or Grout Inspection by.. Date Final Inspection by b Date: L�' ]L p <br /> Additional Comments: 71 ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-d621 ❑ 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 Ile <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> a EH 13-24(REV. /n 51 .E <br /> EH 14-26 -t] ��L <br />