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APPLICATION FOR PERMIT <br /> 4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> i 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 /> A <br /> i city F Lot Size PM <br /> I Job Address <br /> iy <br /> Owner's Name t Address. - Phone <br /> e <br /> t - <br /> k Contractor ss No. Phone <br /> TYPE OF WELL/PU P: NEW W L LlWELL REPLACEMENT ❑ DESTRUCTION b <br /> PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER L'DISTANCE TO NEAREST: SEPTIC TANK - SEINER LINES . 11% "DISPOSAL FLD. PROP. y�INE <br /> f FOUNDATlON ' AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open ottom ❑ Manteca Dia. of Well Excavation �, Dia. of Well using <br /> ❑ Domestic/Private ❑ Grav I Pack ❑ Tracy Type of Casing E . peciflcation <br /> ❑ Public ❑ Ot 'r '' elta Depth.of Grout Seal Type of Gro <br /> ❑ Irrigation pprox. Depth Eastern ce Seal..Installe by <br /> Repair Work Done ❑ Type f Pump H.P, ate Work Done <br /> Well Destruction ❑ Well iameter Sealing Material Ito A <br /> Dept 'Filler Material )Belo <br /> TYPE OF SEPTIC WORK: N INSTAL TION REPAIR/ADDITION ❑ DESTRUCTION ❑ septi s , r if public sewer is <br /> ` a liable i fee ) <br /> Installation will serve: Residenc r Commercial Other f <br /> I Number of living units: mber of bed oa s l } <br /> I <br /> _ <br /> Character of soil to a depth of 3 fee Wat r table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No, ompartmenis r. <br /> PKG. TREATMENT;,PLT. ❑ _ . .� j. ' �i, �' Method of DispQsak <br /> Distance to nearest: Well _102 Foundation"",Z Property Line <br /> LEACHING LINE f ' No. & Length!of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: - Well Foundation Property Line <br /> SEEPAGE PITS Depth Size .Number' <br /> SUMPS ❑ Distance to nearest: Well _ Foundation _ Property Line__-. � <br /> DISPOSAL PONDS ❑ <br /> 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 oomperisation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that it 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." F <br /> The applicant st all 11 =1redct ns. Complet dr ng on r side. <br /> Signed r itle: Date: <br /> FOR DEPAY / <br /> Application Accepted by •Date _< J <br /> Pit or Grout Inspection b Dat�OV <br /> on by r Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 y ❑ Manteca 823-7104 ❑ Tracy 7ox / <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. , Stk., CA 95201 <br /> 9 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASµ RECEIVED BY DATE PEFIMIV NO. <br /> r INFO <br /> + EH 5324)REV.I/a 57 <br /> EH 14-26 s <br />