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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 'I'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 /> f <br /> Job Address. -" ' > City Lot Size P <br /> Owner's Name z Address Phone <br /> Contractor ress gn , No, Khone; <br /> TYPE OF WELL/P MP: IV EW WE L ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> } PUMP INSTALLATION:.c SYSTEM REPAIR ❑ OTHER ❑ <br /> I DISTANCE TO NEAREST: SEPTIC TANK .# SEWER LINES DISPOSAL FLD.' PROP. LINE <br /> FOUNDATION ' AGRICULTURE WELL _OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private [i Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I F] Public ❑ Other I ❑ Delta Depth of Grout.,Seal Type of Grout <br /> i I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump "'-- - -HcP-- - = - State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material.(top 50' <br /> Depth ° Filler Material {Bela ') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i.l REPAIR/ADDITION [V DE=STRUCTION 1-1 (No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: a Residence 6 Commercial— Other `F <br /> 02 <br /> Number of living units: r Number of bedrooms <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 /> I <br /> LEACHING LINE ❑ No. & Length of lines 12 Total length/size <br /> FILTER BED ❑ Distance-to nearest: Well Foundation 424 Property Line <br /> I 1 <br /> SEE PITS i I Depth a Number <br /> SUMPS *" Cl Distance to nearest: Well Foundation 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 /> certifies the following: "I certify that in jthe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." 9 <br /> The applicant t cal rail re fired i ions. Comple4 rawing on eve se side. <br /> Signed X f Title- Date: <br /> f FOR DEPARTMENT USE ONLY <br /> ApplicAtion Accepted by Date Area Z <br /> rout ns4d,t ai n by Date Final Inspection by t <br /> - � 1 <br /> r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-685 <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 /> t w <br /> +.EH13-24(REV.1/H 51 <br /> EH 11-28 - I <br />