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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA Q <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r install the work <br /> n described. This <br /> cation is <br /> madle in(compion isliance weiebyrith SanoJoaqu tthe n Cou Joaquin Ordinan Joauin lHealth District for a nce No.549 for sewage or permit <br /> No. 1862 forcwe I/dpuomp and the Rules and IR Regulations of the San Joaquin <br /> Local Health District. <br /> City � Lot Size PM <br /> Job Address JJ <br /> Owner's Name <br /> U Address I Uvs,f� Phone G 9 <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP k TALLATION ❑ SYSTEM REPAI OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PROP- LINE <br /> FOUNDATION AGRICULTURE LL OTHER WELL PIT5ISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom an Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack r Type of Casing Specifications <br /> I'l Public ❑ Other ❑ Delta Depth o1 Grout Seat Type of Grout <br /> I ) Irrigation -Approx epth l I Eastern Surface Seal Installed by - <br /> i <br /> Repair Work Done ❑ Type of p H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 —� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION l I DESTRUCTION INo septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> 1 Installation will serve: Residence— .Commercial` Other <br /> Number of living units: Number of bedrooms f <br /> Character of soil'to a depth of 3 feet: Water table depth �. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> i <br /> PKG. TREATMENT PLT. ❑ - Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well. Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L� 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 doe in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health D%i trict. <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 /> F 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 M1.6, cal or a r ired '01pections. Complete drawing an reverse side- 0 <br /> r — <br /> � Date: i <br /> ! Signed X Title: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by on Date ` '� Area + - <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 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O- Box 2009, Stk., CA 95201 <br /> AMOUNT DUE AMOUNT REMITTED OKRECEIVED BY DATE PERMIT NO. <br /> [FEE <br /> NFO <br /> + EH 13-241REV.IIA53 3�J �. 3� <br /> EH 14-26 <br />