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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 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. <br /> Jab Address City Lot Size (� PM <br /> Owner's Name <br /> Address [ [ r Phone <br /> Soiw I z8 s <br /> Contract rAddress License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑: <br /> - - PUMP INSTALLATION.0,- ,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 O <br /> 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \, <br /> f-1 Public F Other FI Delta Depth of Grout Seal Type of Grout---- <br /> I <br /> rout_ _I I Irrigation _Approx. Depth i I Eastern Surface Seal installed by . <br /> Repair Work Done ❑ Type of Pump W.P. State Work Done_ <br /> Well Destruction 0 Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION 1-1 DESTRUCTION (No septic system permitted if public sewer is <br /> 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 0 Type/Mfg' Capacity No. Compartments' <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest:' Well Foundation Property Line <br /> r+r`• 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size I f <br /> FILTER BED 0 Distance to nearest: Well t Foundation Property Line s <br /> SEEPAGE-PITS i I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 { <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 D�Itrict. i <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: "l 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 /> Theapplicant ust IL. spections.-Complete-drawing" everse-side <br /> Signed X I Title: Date: (J f <br /> FOR DEPARTMENT USE ONLY k " <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by/ Date Final Inspection by �r Date ��F <br /> Additional Comments: <br /> El Stk" 466-6781 0 Lodi 369-3621 [3Manteca 823-7104 0 Tracy- 835-63$5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDC 8H RECEIVED BY DATE PERMIT'NQ. <br /> INFO <br /> r.EH 13.24 1REV.1/H 51 <br /> EH 14-28 ( „ <br />