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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 and/or install the work herein described.This application is <br /> Mmade 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 /> 1 a, Local Health District. <br /> Job Address / e157 City Lot Size PM <br /> �r <br /> I <br /> F Owner's NameAddress Phone <br /> Contractor "" A/A Address ` License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> f 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 /> t'^ ElIndustrial ❑ Open Bottom 11Manteca Dia. of Well Excavation pia. of Well Casing <br /> EJ Domestic/ C1Gravel Pack LlTracy Type of Casing Specifications <br /> ❑ Public El Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done Jam} <br /> Well Destruction fl Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 507 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ,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 ❑ Type/Mfg CapacityM440 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of D)sposal <br /> 1, <br /> + Distance to nearest: Well _ Foundation 16 Property Line A <br /> LFArHING LINE ❑ No. & Length of lines Total length/size 00 -f 3 <br /> = FILTER 8> D ❑ Distance to nearest: Well Foundation Property Line. �..._ <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to'neatesr" " 'Weli Foundation' Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> Horne oiWier 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:"1 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 f�br all requ'red ins tions. Complete drawing on reverse side. <br /> Signed X � Title: Date: //A <br /> v a 7 <br /> 4 ��3� „ FOR DEPARTMENT USE ONLY <br /> IM <br /> Application Accepted by ,T,�T��_-*T k Date `� -)FArea <br /> Pit or Grout inspection by Date Final Inspection by <br /> Additional 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 INFO AMOUNT DUE AMOUNT REMITTED CK ASH RECEIVEDBY DATE PERMiT140. <br /> + EH 13-241HEV.t/e51 <br /> EH 1424 '.. / <br />