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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON 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 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. Lf / <br /> City. Lot Size PM <br /> Job Address ✓Ns <br /> AddPhone <br /> r Phone <br /> Owner's Name % <br /> �• 'tea " �! License NO._J �� -� Phone <br /> Contractor ,Address <br /> TYPE OF WELL/PUMP:, NEW WELL © WELL REPLACEMENT ❑ `DESTRUCTION <br /> PUMP INSTALLATION ❑ �� - SYSTEM REPAIR ❑ OTHER ❑ <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER�L NESS DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS fi <br /> INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS (1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel!}Excavation Dia. i f Well Casing �� 1 <br /> ❑ Domestic/Private ❑ Gravel Pack �❑ Tracy Type of Casing <br /> Specifications <br /> ❑ Public F1Other I:l_De�lta„ Depthoi Grout Seal Type of Grout <br /> _.-Approx. Depth i I Eastern Suiiace Seal Installed by - <br /> t I I Irrigation �- <br /> ! H p State Work Done <br /> Repair Work Done ❑ Type of Pump ,. il <br /> Well Destructions Well Diameter ,& --�,q j,�ealing Material (top 50'1 <br /> Depth _ at :r Filler Material 18elow 50 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 R AIR/ADDITION 1.1 DESTRUCTION I 1 fNo septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> l' <br /> Installation will serve: Residence Commercial' Other <br /> Number of liVing units: Number of bedrooms ,J I <br /> Character of soil to a depth of 3 feet: II Water table depth <br /> t t Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg ' <br /> PKG. TREATMENT PLT. ❑ # .� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ` <br /> LEACHING LINE 177 No. & Length of lines I Total length/size <br /> FILTER BED EJDistance to nearest: Well Foundation Property Line <br /> SEEPAG QTS I I '3Depth Siie <br /> Number <br /> SUMPS ❑;Distance to`nearest: r` Well Foundation Property Line <br /> DISPOSAL PONDS ❑ f f <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' local Health District. 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 beclome'subject to workman's c ripensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the following: "I certify4t`ha't in the•pertorin�a of the work for whisch this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> T.he_applicant_mu I squired ' t s:-Dampfete drawing on-fever de-- --��-- —Y7 <br /> �- <br /> Signed Xitle: �' Date: — <br /> -DEPARTMENTNUSE\ONLY <br /> Application Accepted by <br /> --_Date. —.Area <br /> I <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 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> lCK 9 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYYATE PERMIT NO. <br /> INFO <br /> + EH 13-21 IREV.I/n sY � a <br /> ` EH 11-28 IA ....� <br />