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Ir APPLICATION FOR PERMIT . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE,,,STOCKTON, CA <br /> Telephone (209) 466-6781 AR. vf� <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 /> 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. <br /> Job Addressi y <br /> City eft ;If/ Lot Size O PM <br /> Owner's Name Address ,C/Q I <br /> Phone <br /> Contractor 5C-_1� Address License No. <br /> TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION ❑ Phone <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL = OTHER WELL PIT <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc <br /> Dia. of Well Casing <br /> F] Domestic/Private LJGravel Pack ❑ Tracy T asin <br /> - g Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout SealT <br /> t n <br /> ype of Grout <br /> ❑ Irrigation ---Approx. De Eastern Surface Seal Installed by <br /> Repair Work Done ❑ T ump H.P. State Work Done_ 1 <br /> Well Destructio Well Diameter Sealing Material (top 50'1 ' <br /> Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑. DESTRUCTION: (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other c <br /> available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Zn Water table depth <br /> SEPTIC TANK Type/Mfg t 1 Capacity No. Compartments i <br /> PKG. TREATMENT PLT- ❑ <br /> i Method of Disposal <br /> Distance to nearest: Well Foundatiorn - Property Line <br /> ------------------ i <br /> LEACHING LINE ❑ No. & Length of lines ITotal length/size <br /> FILTER BED ❑ Distance to nearest: Well w f 'I'duridation Property Line <br /> l <br /> SEEPAGE PITS ❑ Depth Size 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 /> The alicant must call for all required inspections. Co late drawing on reverse side. <br /> el <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date�� <br /> Additional Comments: <br /> i <br /> ❑ Stk 466-6781 ❑ Lodi 3 3621 ❑ Manteca 8234 ❑ 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 gMOUNT DUE AMOUNT REMITTED C RECEIVED BY <br /> INFO r�� /E� ,r1 AS DATE �]. P/E/7RMJIT�N�O <br /> + Ek 13-24(REV. i H 5l `�--. -�lJ :0e� �� <br /> ER 14-29 �4J �[J /A[ ' <br /> i <br />