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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 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 <br /> City 0 Lot Size PM <br /> - Owner's Name ���A -14M �f ,46&P Address Phone <br /> Contractor Address , * ��-License No, c� JPhone <br /> 6�sa� <br /> TYPE OF W L/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> PUMP INSTALLATION ❑ ., SYSTEM REPAIR ❑ OTHER'17 { <br /> DISTANCE TO NEAREST, SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ? <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ".� <br /> ❑ Industrial G❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.,Well Casing. •v <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delfa- --Depth of Grout Seal Type of Grout <br /> LlIrrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State`Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Materiahltop 50'1 <br /> Depth Filler Material IB 10 5501 Y k <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> `Installation will serve: R dente Commercial_____ Other <br /> Number of living units: Nu ber of bedroms_!?_ r �r w <br /> -Character of soil to,a depth of 3 feet: Water table depth h <br /> SEPTIC TANK R ❑ Type/Mfg Capacity No. Compartments f _ <br /> PKG. TREATMENT PET. ❑ ,' ; Method of Disposal i <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines } Total Jength/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation 0 Property-.Line <br /> SEEPAGE PITS & Depth S Size uTber <br /> SUMPS ❑ Distance to nearest: Well 1496.. Foundation Property Line cps <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 applican ust c for all ed inspe on omplete drawing on reverse side. y -� �-- -- ' <br /> � � «� :�� <br /> Signed X __ Title: Date: <br /> i <br /> EPR DEPARTMENT USE ONLY <br /> Application.Accepted by r n Date Area (,[ <br /> Pit or Grout Inspection byDate VFinal Inspection by Date +r" <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-67B1 ❑ Lodi 369-3621 ❑ Manteca`•823-7104 - --O"Tracy'635-6385 <br /> Applicant - Return all copies to: Environmental Health=Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO." <br /> INFO <br /> I + EH13-24-(REV.F/85) <br /> EH 14-26 - �P <br /> i <br />