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APPLICATION FOR PERMIT <br /> :I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ..r <br /> Il PERMIT EXPIRES 7 YEAR FROM DATE ISSUED . <br /> (Complete in Triplicate) I <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 fol;well/pump and.the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Ad � � �✓ - "" ^� F Lot Size PM <br /> 0 ner' Name Address F� � � ! I Phon ^��� <br /> 7 � <br /> /� r <br /> C r 1 (��i7 '. cl� Address License /�� � Phone �� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 /> ��� <br /> Ii (&'Do��mestic/Private LIGrauvel Pack ❑ Tracy Type of Casing Specifications <br /> . Public ❑ Other ❑ Delta y, Depth of Grout Seal Type of Grout <br /> gation _ __,Approx. D ❑ Eastern Surface Seal Installed by <br /> Repair Work Done '❑ Type"of Pum _ H.P. State Work Done <br /> A Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> g Depth Filler Material (Below 50'1 <br /> .. El <br /> ��, TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is is <br /> i, 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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ !I Method of Disposal <br /> TM` e Distance.to,nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size �. ! <br /> K`F FILTER„BED ❑ Distance to neatest: ,`' 'Well Foundation Property Line I <br /> ' r l <br /> ' SEEPAGE PITS ❑ Depth Size Number <br /> t <br /> SUMPS J ❑ Distance to nearest: Well Foundation Property Line <br /> �r r 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 /> f 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 fo owing: "I certify that in th pe rmance f the work for which this permit iS issued, I shall employ persons subject to workman's wmpensa- fd <br /> tion laws of alifornia." :II <br /> The applica t mst call for I uired s ions. g�nplete drawing on rse side. <br /> Signed ` / Title: Date: i <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by Sd?S� � -p-t`^��'�^'�� Date SA L�`'� Area <br /> � - I <br /> i <br /> I Pit or Grout Inspection try �I Qate Final Inspection by Date <br /> Additional Comments:f7K <br /> ❑ Stk 466-6781 ❑ L 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f <br /> Applicant- Return all copies to:. .Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE }AMOUNT REMITTED CASH CK RECEIVED By DATEO, <br /> r� PERMITIN <br /> + EH 13-24(REV.1/85) <br /> EH 1428 ��,J <br />