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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE TON 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 / 6 <br /> City Lot Size PM <br /> 70 { Phone - <br /> Owner's Name Address ` r <br /> -):& <br /> Contract Address Q License No. <br /> ZPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> t <br /> SEWER LINES DISTANCE TO NEAREST: SEPTIC TANK <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications 1 <br /> ❑ Domestic/Private ❑ Gravel Pack Q Tracy Type of Casing Type of Grout <br /> ❑ Public <br /> LJ Other 11 Delta Depth of Grout Seal <br /> Q Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> ( H p State Work Done <br /> Repair Work Done C1Type of Pump <br /> — <br /> j Well Destruction El Well Well Diameter Sealing Material {top 50 <br />! K Depth _ '- filler Material (Below 50'1 <br /> TYPE.OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI /ADDITION ❑ DESTRUCTION Q eNailabpelwithine200 feet.) <br /> tted if public sewer is <br /> i Installation wi1I serve: Residence Commercial— Other <br /> i ,Number of living units: Number of�k}e rooms -.- m.W-— <br /> 1 Water table depth <br /> Cfiaracter of soil to a depth of 3 feet: <br /> z <br /> r Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ +tet <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE V No. & Length of lines ' <br /> Tptallength/size '� <br /> i i FILTER BED ElDistance to nearest: Well!/a C� Foundation property Line <br /> • k � '� Jnr <br /> 0S Size `* Number <br /> SEEPAGE PITS Depth , Y <br /> sumps ! El Distance to nearest: Well fin` Foundation=3 Property Line r� <br /> j DISPOSAL PONDS ❑ <br /> Thereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> i 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 iss`usi r I shall not' <br /> employ any person in such manner as to become subject t6vorkman'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 compensa- <br /> tion <br /> o pensa- <br /> tion laws'of California. <br /> I The appl cant t call for al u'ed inspections. Complete drawing on reverse s!d <br /> y Signed <br /> Title: l - Date: - q <br /> ' r FOR DEPARTMENT USE ONLY <br /> DateArea <br /> a Application Accepted by ? <br /> Date r Final Inspection by Data <br /> Pit or Grout Inspection by i ` <br /> i f <br /> ' Additional Comments: <br /> r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> ` Applicant Return all copies to: Enviffronmental Health Perrnit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> � fia t <br /> CK RECEIVED BY GATE PERMIT N0. <br /> € <br /> IFEENFO AMOUNT DUE AMOUNT REMITTED CASH <br /> t + EHr18-24 1REv.} <br /> ` EH,1429 '- F <br />