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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 /> Job Address4 ��/ ` <br /> r! YV , W City %"_kLot Size PM <br /> i <br /> Owner's Name Address Phone ✓r <br /> ContractorAddress w5z License No. Phon <br /> I TYPE OF WELL/PUMP: WELL WELL REPLACEMENT E7 DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLA. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial [7Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well, Casing <br /> ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public F1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I <br /> I I irrigation _..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump k H.P. State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 501 <br /> Depth _Jgg tp� Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feeL1 r <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms . <br /> Character of soil to a depth of 3 fact: Water table depth <br /> s SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well . Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of.lines Total length/size N, <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll 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 inaccordance 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 /> i 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 follow' g: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of Calif i <br /> The applicant for all required inspections. Complete drawing a;Z0.,W7 <br /> Signed X Title: "Date.: r <br /> FOR DEPARTMENT USE ONLY y <br /> r Application Accepted by T Date !lr Area <br /> Pit or Grout Inspection by Date final Inspection by Date <br /> ` Additional Comments: . <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 /> 4 } <br /> CK <br /> FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH13-24MEV.iiµ51 3�]/ �j� O� �7'� LO� <br /> EH 14.26 <br /> h <br />