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APPLICATION FOR PERMIT <br /> S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1-YEAR 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. <br /> Job Address City Lot Size PM <br /> Owner's Name,R/c, e t Address1 <br /> 0 Phone <br /> Contractor Address min License No. 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 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (I Public ❑ Other 1 F1 Delta Depth of Grout Seal 7 <br /> _ ype of Grout <br /> I I Irrigation —.Approx. Depth I i Eastern `Surface Seal Installed by <br /> Repair Work Done ❑. Type of Pump H.P. State Work Done_ <br /> i <br /> Well Destruction ❑ Well piameter{. Sealing Material (top 50') <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTIO I (No 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 <br /> Character of soil to a depth of 3 feet: f 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 /> I <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size n f <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line V' <br /> SEEPAGE PITS I I Depth I Size <br /> Number <br /> SUMPS L Distance t6 nearest: Well <br /> DISPOSAL PONDS Ll <br /> Property Line <br /> ; (^, <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and l/ <br /> rules and regulations of the San Joaquin,Local Health Dt%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 r <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 st call for all re .red inpectigns. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> F.0 DEPARTMENT USE ONLY <br /> Application Accepted by t Date a� Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3 1 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 - <br /> Applicant - Return all copie§,to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE r <br /> AMOUNT DUE AMOUNT REMITTED PATE ?ERMIT'NO. <br /> CK A <br /> INFO r C SH RECEIVED BY ,�,�y <br /> +.EH i3-24 MEV.tiH5] �,\ �•"ti� �} �,pl � <br /> EH 14-26 C_�� 1! [1 p <br /> I <br />