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APPLICATION FOR PERMIT e75 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601-E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I J, (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 /> J� r7 <br /> Job Address � � r(S� Ci L4 Lot Size/ x PM <br /> Owner's Nam �r� �+� �� Address �/ �/ / Phone <br /> Contractor 5e, Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEARE PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS (� <br /> 1 ANTENDED USE TYPE OF WELL PROBLEM AR NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of a tion 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 El 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 50') <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTI septic system permitted if public sewer is <br /> availa a Mthin 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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance I to nearest: Well Foundation_ "�Property Line <br /> LEACHING LINE El 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 ❑ 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, and <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 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 cert' 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 cal all to red i ctions. Com a dra ing on reverse side. <br /> Signe Title: Date: <br /> FOR DEPARTMENT USE ONLY ° <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by r _ vG Dat <br /> Additional Comments: fJ <br /> ❑ Stk '468 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835 <br /> Applicant Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 1324 TREY.1/e 5) :3 <br /> EH 1126 <br />