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APPLICATION FOR PERMIT 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT W.A <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA 0►j- ,i. +,?�w ' <br /> Telephone (209) 466-6781 N <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> f <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 wo rein described. his a cation 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 o1 the San Joaquin <br /> Local Health District. <br /> City ' Lot Size 100 X PM <br /> Job Address ! <br /> ! -�� �/ Phone <br /> Owner's Name ._ — _ Address <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 FLD. PROP. LIN <br /> FOUNDATION AGRICULTURE WELL OTHER WELL /SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE ONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of cavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy-,- ype of Casing Specifications <br /> M Public n Other a Depth of Grout Seal Type of Grout <br /> I I Irrigation Appr pth l 1 Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ e of Pump WP. <br /> State Work Done <br /> Well Destruct" ❑ Well Diameter Sealing Material Itop 50'! <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION t 1 DESTRUCTION avaiiabetrwithin 200 feetc system .) if public sewer is <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED LJ Distance to nearest: Well Foundation. ^ Property Line <br /> Size <br /> sumps <br /> Number <br /> SEEPAGE PITS FI Depth <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 /> t, The applicant must II for all required inspe ti S. Complete drawing on reverse side. [+� <br /> �_ T"97 <br /> r <br /> Signed X - Title: Date - <br /> DEPARTMENT USE ONLY <br /> I Application Accepted by <br /> Date ^� Area <br /> r Pit or Grout Inspection by Date Final Inspection by Date �® r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 <br /> I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2403, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INIF <br /> EH 1324(REV.r/H 5) - <br /> EH N-26 <br />