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APPLICATION FOR PERMIT <br /> SAN 'JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 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 and/or install the work herein described.This application is <br /> i <br /> made in compliancs,with San Joaquin County Ordinance No.549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin 1 <br /> Local Health Distriot. , <br /> if <br /> City �- ot Size PM <br /> Job Address 5 / <br /> f , <br /> p :•. Phone <br /> Address at ,Owner's Name � Phone <br /> License No. <br /> Contractor's Name DESTRUCTION El <br /> h TYPE OF WELLIPUMP: NEW WELL ❑' WELL REPLACEMENT ID <br /> PUMP INSTALLATION F-1SYSTEM REPAIR ❑ <br /> HER IJ'-'�� <br /> SEWER LINES DISPOSAL FLD'1 - PR'OP, LINEA <br /> DISTANCE TO NEAREST: SEPTICTANKf AGRICULTURE WELL. - OTHER WELD PITS/SUMPS <br /> % _ •, i, FOUNDATION a <br /> INTENDED USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavat oh w <br /> ❑ Industrial Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> S <br /> ❑-Delta Depth of Grout eal Type of Grout <br /> ❑ Public 1 ❑ Other ' <br /> D Irrigation _—Approx 1 Depth ❑"Eastern Surface Seal Installed by <br /> Repair Work Done [I Type of Pump <br /> "State-Work-Oone <br /> I ' Sealing Material (top 50') <br /> t Well Destruction ❑ Weil Diameter p , <br /> Depth Filter Material (Bei w 50') <br /> TYPE OF—SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTflUCTION.❑ alvailable�wihine200 feat.m pe ) if sewer is <br /> -�, . <br /> Installation will serve: Residence Commercial_ Other. <br /> Number of living units: Number of bedrooms Water table depth k <br /> Character of soil to a depth of 3 feet: No. Compartments ` <br /> SEPTIC TANK ❑ Type/Mfg Cap city , <br /> Method of.Disposal <br /> PKG. TREATMENT PLT. ❑ ) '6 �'•`Y_ � <br /> e <br /> Distance to nearest: Well n <br /> Foundation Property Lif <br /> n erigih/size E <br /> LEACHING LINE ( No. & Length of lines <br /> Property,Line <br /> FILTER BED ❑ Distance to nearest: Well 77- .�,�oundation. � �, <br /> { <br /> d . Depth I <br /> Size Number <br /> SEEPAGE PITS Pro Line <br /> SUMPS ❑ Distance to nearest: Well Foundation Property <br /> DISPOSAL PONDS ❑ - <br /> q 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 signature <br /> shat not <br /> ring or sub <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contracto Contractor's <br /> subject to workman's-contracting <br /> I certifies the following:"I certify that in the performance of the work for which this permiYis issued,I shall employ pe j <br /> tion laws of California." <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. —2 <br /> Title: Date: <br /> Signed nctr FOR D PARTMENT USE ONLY / <br /> Application Accepted by �• <br /> Date Area / <br /> Date <br /> Date Final Inspection by <br /> I Pit or Grout Inspection by r� <br /> { Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 C Manteca 823-7104 ❑ 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 AMOUNt DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> ChM ' grip OJ <br /> + EH 1324IREV.101931 �.� _.. <br /> F"1l-2Fl <br />