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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ~ <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and ReguApplication 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 /> Local Health District. lations of the San Joaquin <br /> Job Address 3� J <br /> �" ' Citys &c < `7 Lot Size <br /> PM. <br /> Owner's Name �S rL(Z Address '5 A' <br /> Phone to IP <br /> Contractor �G(rr Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLb. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial i . <br /> L] open Bottom ❑ Manteca Dia. of Wel! Excavation I <br /> ❑ Domestic/Private ❑ Grave! Pack ❑ Trac T .` h Dia. of Well Casing <br /> El Public Type of Casing Specifications <br /> ❑ Other [ Delta Depth of Grout Sea! <br /> ❑ Irrigation - - - - '' - — Type of Grout <br /> g "_ �4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H p <br /> Stale Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if Lpublic sewer is <br /> Installation will serve: Residence— Commercial_ Other available within 200 feet.)� <br /> z <br /> w_Number -- <br /> of living units: Number of bedrooms <br /> Character of soil to a depth of 3-feet: ` <br /> tWater table depth <br /> SEPTIC TANK �!� O Type/Mfg r Ca acit� <br /> P Y No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ 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 <br /> DISPOSAL PONDS ❑ Property Line <br /> at-the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and ih <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 cornpensa- <br /> tion laws of California." <br /> The applicant m call for all required inactions. Complete drawing on reverseside: ' <br /> Signed C <br /> Title i / <br /> ' Date: / <br /> FOR DEPARTMENT"§E ONLY/ - <br /> Application Accepted by Da117 I <br /> Area D <br /> Pit or Grout inspection by Date Final Inspection <br /> Date Av Date <br /> Additional Comments: <br /> ElStk 466-6781 17Lodi 369-3621 171Manteca 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 AMOUNT DUE AMOUNT REMITTED <br /> INFO C K RECEIVED BY DATE PERMIT'NO. <br /> + EH 13.24 4REY. <br /> EH 14-26 <br />