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W 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 t <br /> (Complete in Triplicate) M� <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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address � _.3 F City � aLzt <br /> ✓ eF � ot Size_ PM <br /> Owner's Name ` V-3�J Address _!4!"t If N Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE [1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca a Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack © Tr Type of Casing Specifications <br /> FI l Public ❑ Other Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ox. Depth I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ype of Pump H.P. State Work Done <br /> Well E)estr ❑ Well Diameter Sealing Material {top 50'I (� <br /> Depth Filler Material (Below 50') U Il <br /> 49 <br /> TYPE OF SEPTIC WOR!(: NEW INSTALLATION i l REPAIR/ADDITION { I DESTRUCTION I (-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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size 121b _.Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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 persons subject to workman's compensa- <br /> tion laws of California." <br /> Thicant must call to all required inspections. Complete drawing on reverse side. <br /> Signed X 'A, Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area O <br /> Pit or Grout Inspection b Date Final Inspactiw Date G" <br /> Additional Comments: x v, <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man 523-7104 U Tracy &35-6385 <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 REMITTED RECEIVED BY DATE PERMIT-NO. <br /> INFO ''`` CAS <br /> + EH 13-241REV.i/H5) �" 0V l J <br /> EH 14-26 <br />