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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED-. ,w <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 Y, <br /> Local Health District. <br /> Job Address t City Lot Size PM <br /> 1 <br /> Owner's Name ress, Phone <br /> Contractor Address CLoiNcense No. 3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 r <br /> ElIndustrial LlOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Y ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump { H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ptic system permitted if public sewer is <br /> available within 200 feet:) <br /> Installation will serve: Residence— Commercial-r- <br /> Number of living units: Number of bedrooms I <br /> Character of soil to a depth of 3 feet: -, s Water table depth <br /> SEPTIC TANK ❑ Type/Mfg } Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ k Method of Disposal <br /> Distance to nearest: Well,i -Foundation­7--:-Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> ` FILTER BED ❑ Distance to nearest: Well Foundation +. IProperty Line <br /> SEEPAGE PITS ❑ Depth * Size S Number <br /> I SUMPS ❑ Distance to nearest: Well Foundation -!Property Line <br /> I DISPOSAL PONDS ❑ <br /> 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 /> 4 employ any person in such manner as to become subject to workman's.compensation-laws.of_Caiifornia.'• Contractor's hiring or sub-contracting signature <br /> ifias 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 o California. <br /> The applic n ust all fora ed ins ti s. plate drawing o rev <br /> Signe Title: Date: <br /> I-PO <br /> R DEPARTMENT USE ONLY <br /> y Application Accepted by Date �� Area Q�J <br /> Pit or Grout Inspection by Date Final Inspection by Date G/ <br /> Additional Comments: <br /> [ ❑ Stk 466-6781 ❑ Lodi 369_3621Tra --- ------ --- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> t AMOUNT DUE AMOUNT REMITTED CASH t0 RECEIVED BY DATE PERMIT'rNO. <br /> + EH 13-24{REV.(/n5l INFO 00 42,3 141"19-1 'I <br /> EH 14-26 <br />