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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> S � r <br /> JCrty Lot Size <br /> Job Address PM <br /> Owner's Name Address Phone <br /> 77L` s � =1 - Z <br /> Contractor Address lV License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ O, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AT <br /> WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLENSTRUCTION SPECIFICATIONS \ <br /> ❑ Industrial ❑ Open Bottom ❑ Mant . of Weil Excavation Dia- of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracye of Casing Specifications — <br /> I'1 Public n Other H Deltapth of Grout Seal Type of GroutI I Irrigation �.Approx. Depth 1 I Easterface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Or REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: =51 Water table depth <br /> -1 <br /> SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ . Method of Di osal' <br /> Distance to nearest: WelllFo ndation 6-kProperty Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation &:ZC) Property Line <br /> r <br /> SEEPAGE PITS 1 1 Depth ? Size A Number <br /> SUMPS 0 Distance to nearest: Well l� % Foundation Property Line <br /> DISPOSAL PONDS <br /> 1 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 Di§trict. <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."Contractors 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 m t call for all uired ins tions. Complete drawing on reverse side. / �j r <br /> Signed X Title: c Date: / A <br /> FOR PARTMENT USE ONLY J � <br /> Application Accepted by Date ` Area <br /> or Grout Inspection by r _f_D(Jt, inal Inspection 13y � `DateP <br /> Additional Comments: <br /> ❑ Stk 466-6781 . ❑ Lodi 369-3621 a 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO /CASH <br /> ♦ EH13-24(REV,I/AS) <br /> EH'14 2t1 <br />