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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 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 andlor 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. n �� � <br /> � City Lot Size 0.�AX_-f PM <br />� Job Address <br /> }r Q M.1 i Address r� i1 u`" WIIA� Phone <br /> Owner's'Name <br /> License No. Z ZZ� Phone �J <br /> Gontract8r/�� � Address <br /> ' TYPE OF WEL IVIP: NEW WELL ❑ WELL REPLACEMENT LJ _,_.RUCTION ❑ <br /> P <br /> PUMP INSTALLATION Ll REPAIR F1 OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS .� <br /> ` FOUNDATION _AGRICULTURE WELL OTHER,WELL - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> EI industrial (DOpen Bottom ❑ Manteca Dia. of Well Excavation <br /> T e of Casing Specifications <br /> ❑ Domestic/Private Cl Gravel Pack ❑ Tracy yp g� Type of Grout <br /> ❑ Other ❑ Delta Depth of_Grout Seal yp <br /> I-1 Public t - ' z _ <br /> I I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by — <br /> Repair Work Done L7 Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material itop 501 ) <br /> Depth ler Material lBelow 50'1 - <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 EPAIRI DDITION DESTRUCTION I l�availablelwithine200 feet.) if public sewer is <br /> Installation will serve: Residence r Commercial— Other � <br /> ` Numboms 1 <br /> Number of living units: er of be <br /> �. h"f ,, = Water table depth 7 <br /> i Character of soil to a depth of 3 feet: _ ._. wj / <br /> 5EPT1C TANK ❑ Type/Mfg. Capacity No- Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line I <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of-lines <br /> FILTER BED ❑ Distance to nearest: Well ' Fou dation Property_Line' <br /> 1 _ <br /> SEEPAGE PITS I I Depth Size x? Number A <br /> r �t a <br /> -SUMPS X Distance to nearest: Well Foundation Property rtY Line--��-- <br /> w DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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. ork for which this permit is issued, i shall not <br /> _. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the w <br /> mpensation laws of California." Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's co <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 ust tali f all r quired inspections. Complete drawing on reverse s'd <br /> Title: <br /> Signed Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date r� � Area Z � <br /> Application Accepted by <br /> I Pit or Grout Inspection by <br /> Date Final Inspection b;-` J - Date~ f <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635 63$5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 {� <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> ♦-EH 13-24(REV.II <br /> EH 14-29 ` 1 <br />