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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA W EL o__ <br /> Telephone (209) 466-6781 h /{ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N*a ,b� a1 . <br /> .p (Complete in Triplicate) r A5 <br /> iW � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here•,�!in describ,ed. This application is <br /> made in compliance with San J*-�. ,n,.nsceNo.549 far sewage or No. 1862 for well/purr and the Rule6 and Regulations of the San Joaquin <br /> Local Health District.,` <br /> i;. , .Job Address C-! � Lot Size PM <br /> Owner's NameAddress PhoneContract License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLO. PROP <br /> FOUNDATION AGRICULTURE WELL OTHER WE L PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA " CONSTRUCT! IFICATIONS <br /> ❑ Industrial ❑ Open Bottom Cl Manteca D' ell Excavation Dia. of Well Casing f <br /> } 3 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing __ Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work D Type of Pump H.P. State Work Done_ <br /> We ruction ❑ Well Diameter Sealing Material (top 50') 1 - <br /> Depth Filler Material {Below 50') 1' _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> f available within 200 feet.l <br /> Installation will serve: Residence - Commercial_ Other <br /> Number of living units: Number of bedrooms j <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 l <br /> Distance to nearest: Well Foundation Property Line <br /> 1 _ PLEACHING LINE O No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line - <br /> 1 <br /> SEEPAGE PITS ❑ Depth '# Size Number <br /> SUMPS Y ❑ 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 the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Califor <br /> nt s fo quir ' pections. Comp( a rawing on revpfpe side. <br /> Signed X Title: <br /> Date: <br /> r <br /> OR EPARTMENT USE ONLY } <br /> Application Accepted by �]Date j1 { Area P <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments: <br /> ID Stk 466 6781 ❑rYY�3627 ❑ Manteca 823 04 .r ❑ Tracy 835-6385 - <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 _ 1 <br /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. <br /> + EH13-24(REV.i/xsl <br /> EH 14-28 <br />