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APPLICATION FOR PERMIT L , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> � Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED g� <br /> (Complete in Triplicate) <br /> is <br /> Application is hereby made to,the San Joaquin Locale Health District for a permit to construct and/or install the work herein described. This application 15 <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 /> l 1 42- City Lot Sized/0 PM <br /> Job Address �( <br /> n � e !r OfI P.h �rA Phone /4&53 <br /> Owner's Name Y Address'4 <br /> Contractor_w�P Address <br /> i License,No. Phone <br /> t T PE ALELk/Plfl4[ i NEW WELL ❑ WELL REPLACEMENT DESTRUCTION. � <br /> S PUMP INSTALLATION ❑ SYSTEM REP R ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS <br /> INTENDED USE :TYPE OF WELL PROBLE EA NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy of Casing Specifications <br /> M 1 Public Cl Other Cl De Depth rout Seal Type of Grout <br /> i r A rox. Depth I astern Surface Sea talled by - <br /> I I Irrigation PP P <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material ftop 501 <br /> ' Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feeLl (} <br /> Installation will serve: Residence_ Commercial ~Other <br /> Number of living units: " Number of bedrooms 0 <br /> Character of soil to a depth of 3 feet: y Water table depth <br /> Type/Mfg Capacity <br /> SEPTIC TANK El! fi .1 No. Compartments <br /> PKG. TREATMENT PLT. ❑: �, Method of Disposal ji <br /> Distance to nearest: Well Foundation # Property Line <br /> LEACHING LINE ❑ No. & Length of tines Total length/size a <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> f <br /> SEEPAGE PITS l I' Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Liner <br /> DISPOSAL PONDS ❑ J <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"t <br /> I 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- P <br /> tion laws of California." <br /> Theapplican m t Ca for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> s t <br /> { FOR DEPARTMENT USE ONLY <br /> If r <br /> Application Accepted by Ch pate . �Z y Area <br /> .. F3 <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 835-6385 <br /> I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE AMOUNT DUE A UNT REMITTED CK RECEIVED KBY DATE PERMIT NO. <br /> INFO CASH <br /> + EH1 <br /> 3-24(REV.r/H 51 " <br /> EH 11-28 <br />