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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 '('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. y� <br /> JobAddress / d <br /> City Lot Size PM <br /> Owner's Name ZL,_� <br /> Phone <br /> Contractor �WE <br /> License Nol Phone <br /> TYPE OF WELL/P P: NEW LL ❑ WELL REPLACEMENT Fl DU TRUCTtON ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 /> ❑ Domestic/Private ❑.Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1­1 Public /0 Other F1 Delta Depth of Grout Seal Type of Grout <br /> -- <br /> I I Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. + State Work Done <br /> Wel! Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence L Commercial `Other <br /> Number of living units: Number of be ooms 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ElType/Mfg Capacity _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ l _ Method o1 [�is�o5l <br /> Distance to nearest: Well V 0 Foundation Property Line ` !J <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED El Distance to nearest: Well <br /> _— Property Line O <br /> SEEPAGE PITS 11 Depth, Size Number s <br /> SUMPS ❑\ bistance to nearest: Well Foundation . Property Line d <br /> DISPOSAL PONDS 11 , <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 applicant must call for atl require s ctions. Comp to awing on reverse side. <br /> Signed X Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY / <br /> �Application Accepted by bate '5 — Area <br /> /PiYor Grout Inspection by SCC at — Final Inspection by C pate <br /> [/Additional Comments: 2- <br /> ❑ Stk 466-6781 odt Atslirr Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201. <br /> FEE AMOUNT DUE AMOUNT REMITTED C <br /> INFO CAKSH RECEIVED BY DATE PERMIT NO. <br /> + EH 1 -241REV.1/x51�A-1 <br /> EH 1428 <br />