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f <br /> APPLICATION FOR PERMIT <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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. nn <br /> Job Address Cit <br /> f y Lot Size PM <br /> Owners`Name Address Phone�, �'� i <br /> Contractor Address CO211, _��Phe s <br /> License I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> INE <br /> FOUNDATION AGRICULTURE WELL ELL PITS/SUMPS <br /> INTENDED USE TYPEt]F WELL PROBLEM AREA C CTION SPECIFICATIONS - .v- <br /> ❑ Industrial ❑ Open.Bottom ❑ Mar ec Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack . cy Type of Casing r Specifications <br /> FI Public ❑ Other. ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation x. Depth• 1 1 Eastern Surface Seal Installed by <br /> Repair Work Done ype of Pump H.P. State Work Done_ 4 , <br /> Well Destru ❑ Well Diameter Sealing Material (top 50'1 i <br /> Depth "( Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION No septic system permitted if public sewer is <br /> i .? available within 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 I <br /> SEPTIC TANK ❑ Type/Mfg _ ' Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> P Y <br /> Na <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well L ,Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number— <br /> SUMPS L) Distance to nearest: Well Foundation ..iProperty 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 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 applicant ust call for all required inspections. Complete drawing on revs se side. <br /> Signed ' <br /> g Title: Date: <br /> I <br /> •FOJf-DEPARTMENT-USE ONLY <br /> Application Accepted by r Date 7 Area <br /> i <br /> Pit or Grout Inspection b Data r. Final Inspection by Date f� <br /> i <br /> Additional Comments: j <br /> ❑ Stk 466-6781 ❑ Lodi 369- 621 ❑ Manteca 823-7104 T acy 835-6385 {I <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. ' <br /> INFO <br /> a EH 13-24[REV.1/H51 2 (� 0 /J�'� O f— <br /> EH 14-28 J L/ !/ <br />