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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781aLl <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 7 6/k/ <br /> 5(p(,de S le dv Cornplete 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.,fy�r+¢ ; <br /> Job Address City Lot Size PM <br /> Owner's Name- Vicense <br /> ss F T Phone ' <br /> Contractor's Name No. [ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENY ❑ 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS lof <br /> ❑ Industrial ElOpen Bottom 13Manteca Dia. of Well Excavation Dia. 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 yApproz Depth {O Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump A H.P. State Work Done I (� <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: J_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table,depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments x <br /> r <br /> PKG. TREATMENT PLT. ❑ r Method of,Disposal. <br /> Distance to nearest: Well 400 Foundation _ Property Line �.0 . <br /> LEACHING LINE S+ No. & Length of lines ..__ .._._Y� Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line r <br /> SEEPAGE PITS Depth Size !)J# 11lumber L3 <br /> SUMPS ElDistance to nearest: Well Foundation c 3 40 Property Line " <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work,will 6 done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. t\� .. <br /> vf <br /> Home owner or licensed agent's signature certifies the followingv'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 slaws of California."Contractor's hiring"or sub-contracting signature i <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 applicant m r all requir spections.;Compl wing on ase side. <br /> Signed X Title: Date: <br /> + FOR DEPARTMENT USE ONLY 3 <br /> Amp lice o Accepted by J Data I01_21 Area <br /> i Grou'#Alnspection by_ X' Dete �� ' 1 Final Inspection <br />� ~Additional Comments: — <br /> ❑ Stk 466-6781 ❑ Lodi 3fi9-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <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 CK RECEIVED BY DATE PERMn NO. <br /> INFO CASH <br /> + FH 13-241'REv.i0183F s/ - <br /> EH_ 14-26- <br />