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I' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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. 549 for sewage or No. 1862 for well/pump and the Rules and`Regulations of the San Joaquin <br /> Local Health District. <br /> 4;py <br /> Job Address .t Size <br /> r PM <br /> r <br /> Owner's Name <br /> Phone <br /> /J /� } <br /> d res C `11 d' cense Na. Phone / <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEM NT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS - "` ------�_ �' <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationI <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public n Other 171 Delta Depth of Grout Seal Type of Grout _ <br /> I f Irrigation —- <br /> �Approx. DuAh I I Ea tern rface Seal Installed by <br /> Repair Work Done 12 Type of Pu H.P. I ��- State Work Done _ { <br /> Well Destruction ❑ Well Diameter1/! Sealing Material )top{50`1'i l <br /> Depth �t Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION I I DESTRUCTION ( i-(Nolseptic system permitted ill public sewer is <br /> available within 200 feet.] <br /> Installation will serve: Residence_ Commercial_� Other O <br /> Number of living units: Number of bedrooms l <br /> Character of soil to a depth of 3 feet: <br /> i a pacWa <br /> ' ter to le depth <br /> SEPTIC TANK LJ4❑ C }Type/Mfg City �r f( No. Compartments <br /> PKG. TREATMENT PLT. ❑ --. Method-of Disposal 1 i <br /> Distance fo`nearest: " Well^—"Foundation Properly Line—�" <br /> PrLEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth Sire _ Number <br /> SUMPS ❑ Distance to nearest: Well <br /> Foundation Property Line : <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,ilaws, 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 employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican skcallr ired inspecgons. Complete drawinjon evr e sid <br /> Sig d Title: Date: !/ <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �� r Area <br /> Pit or Grout Inspection by Date Final Inspection by r� Dat <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 RECEIVED BY r DATE PERMIT NO. <br /> INFO CASH CK <br /> r� <br /> -EH 13-24{REV.i/n 5� '" - •_ } <br /> EH 14-26 <br />