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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 and/or install the work herein de <br /> Joaquin County scribed. This application is <br /> made in compliance with San Joa <br /> q ty 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 /> Job Address <br /> City 7VL Lot Size PM <br /> Owner's Name Address T r Phone <br /> F <br /> Contractor 14 I.,4, f LC.� Address e�1%� License No— e%;,{ � Phone <br /> F <br /> TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT IDDESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl <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 /> r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia._of Well Excavation Dia. of Well Casing <br /> F, ❑ Domestic/Private ❑ Gravel Pack CI Tracy Type of Casing Specifications <br /> ❑ Public ❑ 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 _ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> i Installation will serve: Residence Commercial Other <br /> ± Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: G- Water table depth <br /> ' SEPTIC TANK F1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> - Method of Disposal <br /> Distance to nearest: W06 Foundation Property Line <br /> LEACHING LINE Cl No, & Length of lines <br /> Total length/size <br /> } FILTER BED �1 ` "-? <br /> Distance to nearest: Well lG'e— Foundation­46:/7 Property Line <br /> SEEPAGE PITS ❑ Depth „_Size :� Number <br /> SUMPS ❑ Distance to nearest: Well ,6 �Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <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:"I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- <br /> tion laws of California." <br /> ► The applicant must call far II required inspections. Complete drawing on reverse side. <br /> Signed X—,,;;;F- �. s � Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 95.201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> FEH 57-24 01 EV.I/K 5> <br /> EM I4-26 -aa�— <br /> r <br />