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APPLICATION FOR'PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> 1601 E. HAZELTON AVE-.-,-STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 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 /> Job Address Ci Lot 5iz ` PM <br /> Owner's Name Addre 1 ! Phone <br /> Contractor's Name ° No. Phone Q <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑T -w.. OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL L PITS/SUMPS W <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing CA <br /> I-] Domestic/Private C] Gravel'. <br /> Pack El Tracy Type of Casing I Specifications j <br /> ❑ Public ❑ Other_. ❑ Delta Depth of Grout Seal I Type of Grout <br /> ❑ Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type If H.P. v State Work Done <br /> i <br /> Well Destruction ❑ _Well biameter Sealing Material Itop 501 i <br /> Depth - Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Resi encs-- ..—Commercial H .4. ther r , <br /> Number of living units: Number of,bedrooms <br /> � 4 <br /> Character of soil to a ep of 3 feet: __ Water,table depth <br /> SEPTIC TANK Type/Mfg Capacityjj_00 No. Compartments <br /> PKG..TREATMENT.PLT. ❑ I� � Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> E r <br /> LEACHING LINE X No. & Length of lines a Total-length/size <br /> ` FILTER BED , ❑ Distance to nearest:' Well Foundation 14� Property Line <br /> SEEPAGE PITS ❑ Dept Size Number 0A, <br /> k SUMPS Distance to nearest: Well Foundation Property Line. <br /> DISPOSAL PONDS ❑ _ __ t, t• ' k/i.�`. <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. t `�W <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 a 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 app nt m aA quir ' s do . Com awing on r side. <br /> ' t <br /> Signed Title: Date: <br /> FOR DEPA TMENT USE ONLY <br /> Application Accepted by 'r `� Date �0� Area O� <br /> Pit or Grout Inspection by r Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 /> .4 <br /> FEE <br /> INFO AMOUNT <br /> DUE AMOUNT REMITTED CASH CK RECEIVED BY DpATE�/ PERMIT' <br /> NrO. <br /> + EH 13.24{REV.101831 _ \ .^-.._Y �... ... �, _ .. _�.0. -!_ �!`SU <br /> EH 14-28 <br />