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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {200} 466-6781 <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> XApplication eby made to the San Joaquin Local Health District for a permit to construct and/or install the w,"herein described.This application is <br /> ce with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules,nd Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 5 CLot Size PM <br /> 1 ' <br /> Owner's Name Y Address +* T Phone <br /> a G., <br /> Contractor l! <br /> �jcn�,eNo/ &&Phone <br /> TYPE OF WELL/PUMP` NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION <br /> V. <br /> PUMP INSTALLATION 11SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r FOUNDATION `" AGRICULTURE WELL OTHER WELL �PITSlSUMPS tjy <br /> f <br /> INTENDED USE TYPE OF WELL ! `PROBLEM AREA CONSTRUCTION SPECIFICATIONS r�' <br /> ❑ Industrial ❑ Open Bottom i ❑ Manteca' Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack LlTracy Type of Casing Specifications <br /> ❑ Public { ❑ Other ❑ Delta f Depth of Grout Seal Type of Grout <br /> F <br /> ! "❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> G Repair Work Done ❑ Type of Pump <br /> H,P, State Work Done t <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet. <br /> � r <br /> Installation will serve: Residence C t1mmercial Other, <br /> Number of living units: Number ofibedrooms ' r� - 0�" <br /> Character of soil to a depth of 3 feet: ' Water table depth <br /> SE'PTIC TANK; +•"-❑ Type/'Mfg 44 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method Di osal f <br /> Distance to nearest: Well Foundation, Property Line m <br /> k , <br /> LEACHING LINE No. � Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ell Foundation �' y' operty Line �r' r <br /> �� <br /> SEEPAGE PITS Depth Size ' Numtie�� �Line <br /> SUMPS ❑ Distance to nearest: Well � ®J�Y-� FoundationProp <br /> r *k'• <br /> DISPOSAL PONDS ❑ <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joa4uin county ordinances, state laws, and" <br /> I rules and regulations of the San Joaquin Local Health District.. 4. r ,y <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of Kqm fior which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws 6f California."Contractor's hiring or sub'contr'acting 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 /> tionlaws of California." ? <br /> The applicant all. all re (red in ti ns. Complete dr 'ng on r side. . <br /> Signed Title: Date: �. <br /> f' f <br /> I r o FOR DEPARTMENT USE ONLY <br /> Application.Accepted by — --Dater' rea 1 <br /> I Pit or Grout Inspection b Date��Final Inspection bye t Date �� <br /> I20 "V0.)aci01� <br /> `Additional Comnierits: - ? <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-1104 ❑ Tracy s 5 i ., <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 y 11 •� � t i. <br /> CK <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r <br /> INFO <br /> + EH 1324(REV.1/e 5) 1 <br /> EH W28 <br /> f <br />