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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 Lel `.- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is he`eby 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 l <br /> Owner's Name 9, 0 ddress � 7 Phone ""2—/ <br /> Contractor �,xe ��.i Address License No. Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE AGEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. � PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PS C <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT! CATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca . o ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Type of Casing Specifications <br /> f'l Public Ll Other f 1 Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation pprox, Depth I ] Eastern Surface Seat Installed by <br /> _• Repair Work Do Type of Pump H.P. State Work Done _ <br /> Well ction ❑ Well Diameter Sealing Material (top 50'1 <br /> r <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION ! I DESTRUCTION (No septic system permitted if public sewer is <br /> 1 f 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 j <br /> SEPTIC TANK 1 ❑ Type/Mfg ° Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ±, fr I } 4 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> R � <br /> LEACHING LINE ❑ No. & Length of,Iines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> r <br /> SUMPS L� Distance to nearest: Well Foundation Property Line <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, l shalj 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 f (lowing: "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 alifornia." <br /> The applica st c r all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: 1�7 IQ <br /> FOR DEPARNT USE ONLY <br /> Applicetl n Accepted by2 Date 1— y Area <br /> Pit or Grout Inspection by Date Final Inspection b <br /> : Date <br /> Additional Commentsr i/ <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 623-7104 Vb Tracy 635-6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.OfiTc tk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED % DK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> r EH 3-24(REV i/n51 ,03 <br /> - EH <br />