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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> ' 1601 E. HAZE T ON AVE., STOCKTON, CA Ff <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> oil <br /> (Complete in Triplicate) <br /> Application is hereby made toSan oaquin 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. . 25 3—3 1-60 –&f <br /> .lob Address amal � �e/�n �� IsIle f10A� ) City Lot Size PM <br /> Owner's Name Address Phone <br /> Contractor -Y' ddressAl- License N0,C26 %/ Phone <br /> TYPE OF WELL/PUMP: NEW WELL E7 WELL REPLACEMENT L DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR] OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD f � '` PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q �J <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> WP <br /> omesticlPrivate ❑ Gravel Pack racy Type of Casing Specifications <br /> ublic 17 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _--Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump �[tl��G H.P. �� State Work Done <br /> Well Destruction ❑ Well Diameter raj Sealing Material (top 501 <br /> Depth &Q ' Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DE=STRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms h <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 11 <br /> Distance to nearest: Well Foundation Property Line r <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size I <br /> FILTER BED ❑ Distance to_nearest: Well Foundation Property Line l j <br /> l 4 <br /> SEEPAGE PITS I 1 Depth Size _ T Number p ` <br /> C7 <br /> SUMPS Distance to nearest: Well 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 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 per on in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the Ilo ing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's campensa <br /> tion laws of Cal' rnia." f <br /> The ap 'ca ust call for a1quired in ction . Complete drawing ri erse side. <br /> Signed X Title: Date: <br /> 1. <br /> F EPARTMENT USE ONLY �. <br /> Application Accepted by Date , , AArea <br /> . . N <br /> Pit or Grout Inspection by Date Final Inspection by Date 's <br /> Additional Comments: rt� rrt <br /> L1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 f <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE P€RMI-'NO. <br /> INFO CASH ! <br /> + EH 13-241REV.1l R5) Igo <br /> Q go, <br /> EH 14-26 ( l <br />