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APPLICATION FOR PERMIT iv o rZ~� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE.,�STOCKTON, CA <br /> ­Telepii8ne•(209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 21.'Se-EQ- 4 (Complete in Triplicate) Zq <br /> Application is here ode to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TNs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health Distr' t. , <br /> Job Addre �' AA <br /> City ize PM <br /> Owner's me i v 1ty Phone '" I <br /> Contractor Address a License No. 12 Phone <br /> TYPE OF WELL/PUMP: + WELL'❑ WELL REPLACEMENT ❑ DESTRUCTION ❑! <br /> PUMP INSTALLATION 11SYSTEAA REPAIR OTHER•,❑ f .° <br /> DISTANCE TO NEAREST: SEPTIC TAW SEWEI LINES �� DISPOSAL FLD. PROP_ LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE '. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r" <br /> ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing, <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f �. <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal pe of,Grout N <br /> ❑ Irrigation pprox. Depth fa tern Sura a Se I Iled by <br /> Repair Work Dane t Type of Pump H.P. State Work Don <br /> Well Destruction ❑ Well Diameter 1 Sealing Material Itop 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is N <br /> v ` 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:-6ompartments <br /> PKG. TREATMENT PLT. 17. 4 Method of Disposal <br /> Distance to nearest: Well Foundation Property tine <br /> LEACHING LINE ❑ - No.'& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS ❑ ' Depth Size Number <br /> SUMPS ❑' Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS q . <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 regulat �,�` Iphearta� <br /> n Joaquin Local Health District. i <br /> Home owner ic,nsed agsignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any erson in such to became sub'ect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies t following:„I certin the perfor a trdr.Wl <br /> or,wh' h this it is issue , I shall erriploy persons subject to workman's compensa- <br /> tion law of Californi . <br /> I <br /> The ap icant m st all all 4uired ' n on re side. J <br /> Signed Date: ` <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ` e—x rtls Area <br /> Pit or Grout Inspection byy Date Final Inspection by1VVa:)CA� Date —X <br /> Additional Comments: <br /> 0 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. Bax 2009, Stk., CA 55201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> + EM 13-24(REV.1/a 5) <br /> EH 14-25 l O <br />