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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 'I'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 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> r i <br /> Job Address City Lot Size PM <br /> I <br /> Owner's tName, Address 4 Phone <br /> r r _ r »_ c. Z <br /> Contract ddress License No. Z z hone J ` <br /> TYPE OF WELL/.PUMP: m. a NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l' f <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j <br /> FOUNDATION Y AGRICULTURE WELL y OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 9 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ° F1 Other ❑ Delta Depth of Grout Seal Type of Grout_ _ <br /> I I Irrigation i --Approx. Depth 19 Eastern Surface Seal Installed by _ <br /> Repair Work Done ' 11 Type of Pump H.P. State Work Done <br /> Well Destruction_ ❑- Well Diameter Sealing Material ftop 501 <br /> ' Depth Material (Below 501 <br /> TYPE OF SEPTIC'WORK: .NEW INSTALLATION 1 ) R£PAIR ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: {-Resi ante-Commercial_ Other <br /> Number of living units: -f- Number of dr o <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest:--* WeII. Foundation Property Line <br /> LEACHING LINE'.r ❑ No. & Leri&i -of lines Total length/size <br /> FILTER BED r: ❑ Distance to nearest: Well Foundation Property Line <br /> I• _ - r(- <br /> IN I <br /> t SEEPAGE PITS._, Depth Size fylumber <br /> _;_SUMPS,_y,. .�yLI,,:Distance.to-nearest:. Well Foundation. Property Line <br /> DISPOSAL`PONDS �s.�❑'s <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordiriances'_state law nd <br /> rules and-regulations of the San Joaquin Local Health Di§trict. <br /> Nome owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this peimiYis issued;d shall not <br /> employ any person in such manner as to.beccime subject to workman's compensation laws of California." Conuactor'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 mu all for all re ire inspections. Complete drawing on rever�seIde <br /> Signed X Title: ^V, �� Date <br /> _p FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date s' �-- Area r� <br /> Pit r Grout Inspection bDate '3—f U—Sy Final Inspection Date ' <« <br /> dditional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT-NO. <br /> r.EH 13-241REV.7/a5i <br /> EH 14-26 <br /> i � <br />