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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA ' <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> IIS 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 /> t 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 /> r <br /> Job Address Il' City Lot Size PM <br /> [,� <br /> Owner's Name II Address .t7r _ Phone <br /> lot <br /> ip / - <br /> Contractor Addres ' 6 1E- License No Phone <br /> TYPE OF WELL/PUMP: hb, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. RBP" <br /> FOIUNDATION AGRICULTURE WELL OTHE PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST RUC PECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ ,Gravel Pack ❑ Tracy Type of Casing !� Specifications <br /> M Public Fl Other elta Depth of Grout Sea! Type of Grout—.-- <br /> Sur <br /> I i irrigation �II -Appro pth I 1 Eastern ace Seal Installed by - <br /> Repair Work Done ❑ T i Pump H.P. State Work Done <br /> Well DestructionWel! Diameter Sealing Material [top 50') <br /> l <br /> e Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC.WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION No septic system permitted if public sewer is <br /> N,available within 200 feet.) <br /> Installation-will serve: Resiblence - Commercial'— Other <br /> Number of living units: } Number of bedrooms <br /> Character of soil to a depth;of 3 feet: 'l i r f Water table depth �+ <br /> SEPTIC TANK ❑ i'Type/Mfg " Capacity No. Compartments <br /> C PKG. TREATMENT PLT. EI Method of Disposal <br /> b Distance to nearest: Well Foundation Property Line <br /> LEACHING LINECl1ii <br /> ' iNo. & Length of tines Total length/size <br /> t <br /> FILTER BED iDistance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I f IDepth` Size 1 Number <br /> I SUMPS ❑ i�Distance to nearest: Well Foundation �.r., f 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 /> L certifies the fallowing: "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." 11 <br /> 1 <br /> The applican ust call for all require in pections. Complete drawing on r rse sid . <br /> t <br /> I - <br /> I <br /> Signed - !� Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> --� 2 <br /> Application Accepted by '�f Date. Area <br /> Pit or Grout Inspection b .4 Date j Final Inspection by Date <br /> I Additional Comments: 1' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man ca H3-7'104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 20W, Stk., CA 95201 <br /> k k it <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT_NO. <br /> + EH 13-24IREV.1/a51 iI. ��� C7t� �`� 1l -2 <br /> EH 14-26 — III <br />