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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAS EL T ON AVE., tTOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work herein describ .This <br /> cation is <br /> madlec n compliance with Sano <br /> oJoaquin County Ordinance the San Joaquin lNo.District Health 549 for sewage or No. 1862 for ell/t to construct dpump and the Rules and R gu ations of he Sang Joaquin <br /> Local Health District. <br /> ' �4 <br /> _ <br /> City Lot Size PM <br /> Job Address <br /> ddress � Phone <br /> Owner's NamN=ame <br /> Phone <br /> Contractor's License No. -� <br /> TYPE OF PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ j <br /> PUMP INSTALLATIO SYSTE RF}PAIR LD DISPOSAL <br /> IR ElIF TO NEAREST: SEPTIC TANK t _ 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 /> t — , <br /> El Industrial ® Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type l Specifications � <br /> `,Domestic/Private ❑ Gravel Pack [].Tracy f "fy yP of Casing <br /> El Public L3 Other ❑kDeka�)�+ Depth of Grout Seal Type�ofAGrout <br /> ❑ Irrigation ZAOk�Approx. Depth ❑ Eastern.. --- Surface Seal stalled by <br /> Repair Work Done El Type of Pump H.P. - State Work Done <br /> Well Destruction ❑ Well Diameter `� Sealing Material (top 50`1 R i <br /> Depth_�.� _ Filler Material (Below 50'1 1 '� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system <br /> m permitted if public sewer is <br /> avaInstallation will serve: Residence— Commercial_ Other <br /> — [>-� <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK El Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT. <br /> El of Disposal <br /> Distance to nearest: well Foundation Properly Line <br /> Total length/sizeLEACHING LINE Ll No. & Length of lines <br /> "� 1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number t <br /> SUMPS ❑ Distance to nearest: Well Foundation Prope i Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with Sari 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 Pg+ or(nance of the work fo*r<vhich this permit is issued; I shall not <br /> employ any person in such manner as to become subject to workman's compensation'tds c5t California°°L�orStractor 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 compensa- <br /> tion laws of California.' <br /> The applicant must call for 11s .required inspectio Complete drawing on reverse side. <br /> . <br /> Signed 1}L�J Title: t�� Date: q <br /> OR PARTMENT SE ONLY <br /> c Date Area <br /> Application Accepted by / <br /> Pit or Grout Inspection by Date Fi Inspection by �l�L Dated <br /> Additional Comments: <br /> D Stk 466`6781 odi 369-3621 El Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copie o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT H REMITTED CA RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> + EH 1324{REV.10183} J/ S. <br /> EH 14-26 <br />