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APPLICATION FOR PERMIT . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE.,.STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) r <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 /> , <br /> Job Address <br /> Cit of Size �' <br /> .� PM <br /> Owner's Name ?p .�. <br /> Address <br /> Phone <br /> Contractor Address <br /> - �--- License No� phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ �l. `.WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP ! T L'LATION ❑ SYSTEM REPAIR ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> OTHER Q <br /> INES DISPOSAL F PROP. LINE <br /> FOUNDATION _ GRICULTURE WELL ELL PITS/SUMPS <br /> INTENDED USE TYPE O,F WELL PROBLEM ARE S ION SPECIFICATIONS " <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca 1a?o I Excavation <br /> Dia. of Well Casing f <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing <br /> ❑ Public ❑ Other Specifications <br /> Delta Depth of Grout Seal <br /> ❑ Irrigation Type of Grout <br /> ---Appro epth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Ty Pump H P <br /> 1 State Work Done <br /> Well Destruction ell Diameter Sealing Material (top 50') <br /> Depth I Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> Installation will serve: Residence CommercialOther available within 200 feet.) <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 fees: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ CapacityNo. Compartments j / <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> �i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED El .Distance to nearest: Well Foundation j <br /> Property Line .- <br /> SEEPAGE PITS F-1Depthy Size <br /> SUMPS Number <br /> ❑,. Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ E Property Line <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." Contractor's hiring or sub-contracting signature- t. <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 must call f r all required inspections. Complete drawing on reverse side. ; <br /> t <br /> Signed X Date: <br /> ' FOR DEPARTMENT USE OfVLY <br /> Application Accepted by Date 0 <br /> Area I <br /> s Pit or Grout Inspection by Date Final Inspection by <br /> t.__ _. a Date <br /> Additional Comments: �r� <br /> ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ fMariteca 823-7104 C7 Tracy 835 6985 7r <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE . <br /> 3 INFO AMOUNT DUE AMOUNT REMITTED 4 CK RECEIVED BY <br /> ©ATE PERMITNO. „� <br /> + EH 1 <br /> 3-24(REV.1/851 �S-�U <br />