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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / ! T <br /> l (Complete in Triplicate) <br /> i <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 City Lot Size PM <br /> a✓lr .cvo'V <br /> Owner's Name �y� Address Phone <br /> t <br /> Contractorr r Address c 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 FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f`1 Public 17-1 Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I 1 Irrigation —_Approx'Depth l I Eastern Surface Seal Installed by _ (� <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION4LI DESTRUCTION I I iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve; Residence_ Commercial 7�(- Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:t Water table depth <br /> SEPTIC TANK / Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ; <br /> I _ Method of Dispose! <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> f <br /> LEACHING LINE D No. & Length of lines ' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS161Depth Size _ Number <br /> SUMPS ❑ Distance to nea_re_st: Well" Foundation Property Line <br /> I DISPOSAL PONDS ❑ v <br /> I hereby certify that I have prepared this application and that the work wil_I 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: "1 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California.:' r1; <br /> The applicant must call for all it spections. Complete drawing on reverse side. <br /> Signed X a Title: Date: -(J <br /> F DEPA MERIT USE ONLY <br /> Application Accepted by Date reaIce <br /> Pit or Grout Inspection by �- Date Final Inspection b Date A& G <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 O 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 95201FEE <br /> " <br /> INFO AMOUNT DUE ' AMOUNT REMITTED RECEIVED BY DATE :PERMIT'NO. <br /> +.EH 13-24 IREV.1/8 51 ` <br /> EH 14-28 <br /> I <br />