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APPLICATION FOR'PERMIT -20 X �/✓g <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7,yd <br /> 1601 E. HAZEL T ON AVE.; STOCKTON, CA !�� <br /> Telephone 52091 466-6781 � <br /> 24 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �� �� 'i <br /> (Complete in Triplicate) <br /> cation is <br /> Application is hereby made to the San Joaquin lHealth No.549 for sewage or istrict for It to construct and/or No 1862 for well/pump and the Rules and all the work IR Regulations of he Sang Joaquin <br /> made in compliance with San Joaquin County � <br /> Local Health District. <br /> / L e? Me <br /> =2z" <br /> City C'- �� PhoneLot Size PM <br /> Job AddressOwner's Nam <br /> Address <br /> Contractor's Name <br /> License No. -Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ' "OTHER WELL PITS/SUMPS 4\ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L3Industrial ElOpen Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing <br /> IF ❑ 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 (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nailabptic sy t m permitted if public sewer is <br /> avle 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 /> 7ne OF <br /> SEPTIC TANK 17Type/Mfg Capacity BLS No. Compartments <br /> PKG. TREATMENT PLT. 11 Method of po al <br /> Distance to nearest: Well ji� Foundation I Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well a foundation Property Line <br /> SEEPAGE PITS ❑ Depth &4 Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 /> fy that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I cert] <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 applicant mu call for all r d inspections. Complete drawing on reverse side. <br /> . lf. <br /> I Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> ..,_- /may ,� o7 <br /> Application Accepted by Date/ Area <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments. <br /> ❑ 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 /> EITTED CK# RECEIVED BY DATE PERMIT'NO. <br /> FE AMOUNT DUE TMNT REM CASH <br /> INFO -~ <br /> � + EH 13-24IREV.10183E <br />