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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No-549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, <br /> Job Address S <br /> -1 tLE <br /> City Lot Size PM <br /> r <br /> Owner's Name Address �--' <br /> t Phone <br /> Contrac� Address <br /> TYPE OF WELL/PUMP: r License Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKOTHER ElSEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ! <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca F <br /> ❑ Domestic/Private 11Gravef Pack Dia. of Well Excavation Dia. of Well Casing I <br /> ❑ Tracy Type of Casing <br /> EJ Public CI Other El Delta Specifications <br /> ❑ Irrigation <br /> Depth of Grout Seal Type of Grout <br /> Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ 'Type of Pump H p <br /> Well Destruction ❑ Well DiameterState Work Done <br /> Sealing Material {top 50'I j. <br /> Depth filer Material [Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L-JREPAIR/ADDITION V DESTRUCTION ❑ INo-septic system permitted if public sewer is <br /> i <br /> Installation will serve: Residence, Commercialavailable within 200 feet.) <br /> Other <br /> Number of living units: _L- Number of b drooms <br /> Character of soil to a depth of 3 feet: -76 <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments r <br /> PKG. TREATMENT PLT- ❑ <br /> Distance to nearest: Well Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE 2*�No. & Length of lines <br /> Tota! length/size O SC � <br /> FILTER BED ❑ Distance to nearest: Well r ti i <br /> Foundation /t3—! Propel Line _ <br /> SEEPAGE PITS ❑ De th <br /> p Size Number <br /> SUMPS ❑ Distance to nearest: Well <br /> Foundation <br /> DISPOSAL PONDS Property Line <br /> 17 � - � - �^�� <br /> hereby certify that 1 have prepared this application and that the work will bd-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 permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant �ust call for II r uired inspections. Complete^drawing on reverse side. <br /> Signed X <br /> --- Title: c P- 0`Q <br /> .--^rr - -- Date: U <br /> FOR DEPART ENT USE ONLY <br /> Application Accepted by <br /> -- _ — - Date Area- <br /> Pit or Grout Inspection by Date Final Iby <br /> Inspection Date <br /> Additional Comments: - <br /> -El'Stk 466-6781' "p CodiT 3G9 3621 Tp 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 <br /> INFO CASH RECEIVED BY DATE ZPERIT'NO- <br /> EH 13-24(REV.ri a s) <br /> EH 14-28 , n, 3 0J <br />