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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 1•YEAR FROM DATE,ISSUED <br /> .v R (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 /> r' 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. !-1. " <br /> � c <br /> Job Address City Lot Size . PM <br /> A N Phone <br /> Owner's Name <br /> Cvntractvr dress_ /-/'-.---.- --,- ___ _ Litense.Na.- - Phoned S�Z <br /> TYPE OF WELL/.PUMPK, NEW WELL ❑ WELL REPLACEMENT ❑ J_, DESTRUCTION ❑ <br /> i3UM_P INSTALLATION ❑ SYSTEM REPAIR ❑ ''' e }'OTHER 0 i <br /> DISTANCE TO.NEAREST: SEPTIC-.TANK. SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION~`~- AGRICULTURE WELL OTHER WELL ' PITS/SUMPS <br /> !INTENDED USE -: TYPE OF'WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS <br /> { r X20 Industrial ElOpen Bottdm ❑ Manteca ,., ' t jpia. of-Well'Excavation ' Dia. of Well Casing <br /> s, ❑, Domestic/Private ❑ Gravel Pack ❑ Tracy �.`."Type of Casing_ ke _ Specifications <br /> �❑ Public ❑ Other ❑ Delta Del <br /> of Grout Seal ' Type of Grout <br /> �❑•Irrigation 'y ---Approx. Depth ❑ Eastern € Surface SealInstalledby <br /> ` Repair Work Done .❑ Type of Pump H.P. ry State Work Done , <br /> 1 Well Destruction r O `Well Diameter' Sealing Material (top 501 <br /> Zf <br /> 'Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence Commercial Other r' <br /> I t <br /> Number of living units: Number of bedrooms <br /> �-� Water tattle depth <br /> r- Character of soil to a depth of 3 feet: <br /> ' SEPTIC TANK ❑ Type/Mfg '- Capacity�2 d - No. Compartments I <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> j Distance to nearest: Well Foundation Property Line 1' <br /> {I. LEACHING LINE El No. & Length of line Total length/size , <br /> I FILTER BED ❑ Distance to nearest: Well: Foundation Property Line <br /> r p f k <br /> SEEPAGE PITS ❑ Depth a-+3 Size Number <br /> SUMPS ❑ Distance to nearest: We11 ^ Foundation Property Line <br /> k <br /> 6 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 r <br /> rules and regulations of the-San Joaquin Local Health District. t <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 st call fora requirad inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> jFOR DEPARTMENT USE ONLY , <br /> Application Accepted by F Date Area Ai <br /> • <br /> Pit I r Grout Inspection by bate Final Inspection by Da 1 <br /> Additionai-Comments:— <br /> ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑ Manteca 823-7104 1] Tracy 835 6385 , <br /> Applicant- Return all copies to: Environmental Health PermWServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> �.... 41 may. <br /> .,.FEE— AMOUNT DUE E <br /> NT REMITTED CK CASH RECEIVED BY DATE PERMiT'NO. <br /> x INFO <br /> + EH 13-24(REV.1/e 5) .�.. - <br /> EH 14-28 ' <br />