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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 112091 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. 1862 for well/pump and the Rules and Regulations of the-San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size 13 / Y�1 <br /> Owner's Name AddressPhone <br /> Contractor's NameNo. Phone <br /> TYPE OF WELL/PUMPf NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR_ ❑ OTHER ❑ ' <br /> 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other © Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation 0---Approx. Depth ❑ Eastern Surface Seal Installed by `n <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction' ❑+ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: `NEW INSTALLATION In REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 11 <br /> 1 available within 200 feet.) <br /> Installation will serve: Residence"' Commercial_ Other <br /> Number of living units: _•I ... Number o bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. CompartmentsI <br /> PKG. TREATMENT PLT. ❑ /{ Method of, DD'' p�jysaI � <br /> r Distance to nearest: Well /D 8 Foundation _ Property Line_ a <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well_. � Foundation L4 Property Line <br /> SEEPAGE PITS C7 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well IAE:On Foundation fib` Property Line t- <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. j <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 must call for all required n pe ions. Complete wing on r e side. <br /> tr <br /> Signed Title: <br /> L� Date: <br /> FOR DEPARTMENT USE ONLY 4 <br /> Application Accepted by Date �� Area <br /> Pit or Grout Inspection by Date Final Inspection b f Date b <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ 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 I INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH R�EC/EIIVED BY DATEPERMMIITT'NO. <br /> + EH 13-24(REV. 10/83) -1 O •VO ft 1 1 ?-31-9b ? /6 . <br /> EH 1426 r`Y <br />