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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> 1601 E. HAZETON AVE., STOCKTON, CA �rn <br /> Telephone (209) 466-6781 U� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applic <br /> Application is hereby maa on is <br /> compliance with San Joaquin County Ordinance Na. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San J quin <br /> made <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address <br /> Phone <br /> Owner's Name <br /> Address <br /> Phone <br /> Contractor <br /> Contractor <br /> Address ,SGr License No. <br /> WELL REPLACEMENT ❑ DESTRUCTION <br /> TYPE OF WELL/PUMP:, NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> El industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ! Specifications <br /> IJ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing <br /> Cl Other n Delta Depth of Grout Seal Type of Grout — <br /> fl Public _ <br /> 1 I Irrigation --Approx. Depth l I Eastern H P State Work Done <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION t DESTRUCTION I I INailaba septic systethin m emitted if public sewer is <br /> avle eet <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 <br /> SEPTIC TANK ❑ Type/Mfg ___ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ElNo. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line r <br /> SEEPAGE PITS I I Depth Size Number <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 Saws, an <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 must call for all required inspections. Complete drawing on reverse side. <br /> Title: O 4 Date: A <br /> X Signed x �� <br /> i FOR DEPARTMENT USE ONLY �7 <br /> f Date �` � Area <br /> Application Accepted by <br /> k Pit or Grout Inspection by <br /> Date Final inspection by A64_ - _ Date <br /> or <br /> r <br /> } Additional Comments: <br /> I{ ❑ 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 /> FEECK RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUEFAM70UNT REMITTED gH <br /> INFO <br /> o eat- �7 �-�S8 <br /> t + EH 13-241REV. /H55 J <br /> EH 14-29 <br />