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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601.E. HAZE 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address v ! ` �J` Cltymm� Lot Size PM <br /> Owner's Name Address Phone <br /> &"s Ag�License No. Phone* W* <br /> Coniractottt <br /> Address] <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation�i Dia. of Well Casing <br /> FYL Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing — Specifications <br /> ❑ Public C1 Other, !E ❑ Delta Depth of Grout Seal J Type of Grout r <br /> I ❑ Irrigation _:—Approx. Depth` # C1 Eastern Surface Seal Installed by <br /> ..�J�6� H.P. State Work Don <br /> Repair Work Done L�ype of Pump [ p <br /> Well Destruction ❑ ,Well-Diameter "r� Sealing Material {top 50'1 r <br /> - 'Depth --- • � ' - ^` Filler Material (Below 50'1 ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ i u septic system permitted if public sewer is <br /> available within 200 feet.) 1 �� <br /> Installation will serve: Residence_ Commercial_ Other <br /> Numberof;living units: Number of bedrooms--!. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> t Total len th/size <br /> LEACHING LINE ❑ No. & Length of lines g <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> 4 SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> rDISPOSAL PONDS 71 �� <br /> Thereby 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 <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." s <br /> -1 <br /> The applicant Title: <br /> usstJttf ca all required inspections. Complete drawing on rse si <br /> AlSigned >,– _,., de. <br /> ,�L� r [4 sip.-.../ D <br /> ate: <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date Final Inspection by Date. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <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 DATE PERMWNO. <br /> INFO <br /> a EH 13-241REV.i/851 A2e5 40 � -71 <br /> EH 1426 ':;}.xr.;..,^ <br />