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APPLICATION FOR PERMiT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> i Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br />` (Complete in Triplicate) <br /> 1 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 /> �fJJob Address �f f' – City Lot Size <br /> i <br /> Owner's Name <br /> r <br /> _— d dress �/� (O <br /> _ PhonLh�p�: <br /> Contractor se— Address <br /> License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LiNES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <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 Casingi <br /> Ll Public L1 Other Ci Delta Depth of Grout Seal Specifications <br /> fications <br /> Grout __ <br /> i I Irrigation - �.,Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of PumpH P <br /> State Work Done I <br /> Well Destruction ❑ Well Diameter{ Sealing Material (top 50') <br /> Depth i Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ) DLSTRUCTION i iNo septic system permitted if public sewer is <br /> t #° available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other O <br /> Number of living units: Num bk of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth [J <br /> SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal f n <br /> Distance to ne t: Wel Foundation Property Line <br /> i <br /> LEACHING LINE ❑ Length of linesx Q <br /> r <br /> FILTER BED distance to nearest: Well oundTotal length/size <br /> ation Property Line <br /> SEEPAGE PITS I 1 Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundatio Property Line V► <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 Di?trict. <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 <br />_ tion laws of California." I em pto <br /> V persons subject to workman's compensa <br /> The applicant must catl for all required in ctions. Complete drawing on reverse side. f <br /> Signed X Title: Date: 3 r r <br /> FOR pE�RTM�ENTUSE ONLY <br /> Application Accepted by ;)f2n Date <br /> 1 Area <br /> Pit or Grout Inspection by Date Final Inspection <br /> Data �' <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 /> FEE AMOUNT DUE AMOUNT REMITTED C <br /> INFO SH RECEIVED BY DATE pERM1T NO. <br /> +.EH 13-21 iREV.1/H 51 i TIN <br /> �- -13 - <br /> EH 14-26 V foJd <br /> , <br /> h <br />