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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 <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 /> - Z Cit <br /> Lots Size"' PM <br /> Job Address <br /> 2Q Phone <br /> Owner's Name Address ik <br /> k <br /> License No. Phone <br /> Contractor Address _ a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing Cf\ <br /> L1 Industrial fl Open Bottom l� Manteca Dia. of Well Excavation i <br /> Type of Casing Specifications <br /> [3 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> 71 Public ' F1 Other n Delta Depth of Grout Seal ! <br /> I.1 Irrigation _Approx. Depth -t I Eastern .y Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done ❑ Type of Pump , <br /> Well Destruction E3 Wed Diameter Sealing Material (top 50'1 <br /> Depth Filler Material(Below 501 ' <br /> LLATION REPAIR/ADDIT <br /> TYPE OF SEPTIC WORK: NEW INSTAION l I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet"1 <br /> Installation will serve: Residence X -Commercial` Other <br /> Number of living units: _.Number of bedrooms — Water table depth <br /> Character of soil to a depth of 3 feet: , <br /> SEPTIC TANK El Type/Mfg CapacityNo. Compartments <br /> _/S�`Ua <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ r�ds <br /> Distance to nearest: We11� Foundation_. Property Line ' <br /> r r <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of linespro Property Line '2-7—0 <br /> FILTER BED ❑ Distance to neatest: Well" Foundati - P Y <br /> Number I <br /> SEEPAGE PITS l I Depth Size_� -- t <br /> SUMPS <br /> t I Distance to nearest Well Foundation Property,Lii"6 <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: 111 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." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance'bYthe work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California e <br /> �- <br /> The appitcantpu0t. call for all require inspections. Complete drawing on reverse side. 4 <br /> Title: Date: <br /> Signed X ; <br /> � PARTfN <br /> FOR EENT USE ONLY [- Z <br /> Date Area <br /> Application Accepted by n <br /> Pit or Grout Inspection by <br /> Date Final inspection by a��( Date <br /> 1 <br /> Additional Comments: <br /> ❑ Stk 466-6781 13 Lodi 369-3 21 '❑ Manteca a23-7104 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> E w CK RECEIVED BY DATE <br /> FEPERMIY NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> t..EH 13.24 IREV"1/H 51 �610 �� • V .. <br /> EH 16-28 <br />