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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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 lork 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 I ules and Regulations of the San Joaquin <br /> Local Health District. l ` <br /> Job AddressGity Lot Size PM <br /> Owner's Name �1 Address Phone Z �"+ `77 <br /> Contractor"Zf 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. LINE <br /> FO DATION AGRICULTURE WELL OTHER WELL PITS/ 7 PS _ <br /> INTENDED USE. TYPE 0 PROBLEM AREA CONSTRUCTION SPECiFICATI0N5 <br /> ❑ Industrial ❑ Open Bottom Dia. of Well Excav Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ing Specifications I <br /> F1 Public Delta Depth of Grout Sea Type of Grout _ <br /> I I Irrigation —.Approx. Depth € I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 11 <br /> Depth _ Filler Material (Below 50') ` al 9 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION [ I DESTRUCTION IN o septic"system permitted if public sewer is <br /> available within 200 feet.} <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms i <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 1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line 'tom <br /> SEEPAGE PITS I 1 Depth Size <br /> Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property lif e <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. I� 1 <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, 1 shall not <br /> employ any person in such ma ner as t become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I cert 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 Calif ia." <br /> The applicant ust, all requireV inspections. Complete drawing on reverse side. 4 <br /> Signed X Title: Bate: / <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> .. ` <br /> p Date t� / ! Area / <br /> Pit or Grout Inspection by aleFinal Inspection by�/,Z_ to Date J <br /> Additional Comments: <br /> ❑ Stk 466-6781 Q Lodi 369-3621 1-7 Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, tk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVEp By DATE PERMIT'NO. <br /> +.EH13-21(REV. i x 51 r[.i+� f,.4-2e G—I>p �J <br /> EH 11(� [ 04 <br />