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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 7 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 Address T 7 4 ~ - <br /> Lot Size PM <br /> Owner's Name ddress ly`� <br /> Phone <br /> Contractor's Name � �, �L � L_L1cense No. S- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM.REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> 1-1 Domestic/Private EI Gravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing Specifications <br /> Ll Public ❑ Other ❑ Delta Depth of Grout Seal {� <br /> ❑ Irrigation — Type of Grout <br /> – <br /> pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION STRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residencecommercial er <br /> Oth _ u - .available within 200 feet.) <br /> Number of living units:. Number of bedrooms �= - <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE �o. & Length of lines Total length/size <br /> FILTER BED L3 Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS IsvDepth Size <br /> Number <br /> SUMPS ❑ Distance to nearest: Weil Foundation <br /> DISPOSAL PONDS Property Line <br /> 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 <br /> laws of California '. permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tionThe aptaftntxr <br /> plete drawing on erse sid . <br /> Signed 1K T ,j% <br /> Title; Date: 1f / C1 <br /> FOR DEPA M�f1fT USE ONLY ��� � <br /> Application Accepted by f�/} Date <br /> Area <br /> Pit or Grout Inspection by r Date Final Inspection byl ►�� <br /> r Data <br /> Additional.Comments: q <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy .885-6385 <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# <br /> INFO — RECEIVED BY DATE PERMIT'N0. <br /> +EH 13-2 (REV.10re31 /S^ � <br /> EH 1426 7 <br />