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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 11,YEAR FROM DATE ISSUED <br /> q (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. i <br /> 40,x� City( =-- Lot Size pM <br /> Job Address W <br /> Owner's <br /> Address / - Phone <br /> ; 7 rLicense No. Phone �• bS <br /> Contrac <br /> rtAddress <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` <br />' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL P175/SUMPS ` <br /> INTENDED.USE TYPE OF-WELL PROBLEM AREA._ CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Industrial r ` I ', Specifications <br /> eType of*Casing i <br /> ❑ Domestic/Private ❑ Gravel Pack i 1 -i]yTraty , <br /> [`1 Public n Other <br /> Delta" v Depth of Grout Seal ' Type of Grout_ - <br /> I l Irrigation —..Apprax. Depth t I Eastern Surface Seal Installed by <br /> .4, H.P , y State Work Done <br /> Repair Work�Done �[3 Type of Pump <br /> Well Destruction ❑ Well Diameter. Sealing Material Itop 50'1 <br /> Depth ' Filler Material (Below 501 —� <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION REPAIRIAADDITION l i DESTRUCTION I I allo septiclable shin system rmil)ed if public sewer is <br /> Installation will serve: Residence Commercial Other— <br /> i � Number of b rooms : <br /> Number of living units: f� ;l <br /> + . Water Sable depth <br />'j Character of soil to a depth of 13 feet:` <br /> E e/Mfg Capacity No. Compartments <br /> SEPTIC TANK � Vp <br /> -PKG. TREATMENT PLT. ❑ Method of Disppsal fi <br /> I' Property Line <br /> Distance to nearest: Well { Foundation , <br /> LEACHING LINE � No. & Length of lines Tota! lengthlsize K <br /> v � < <br /> r Foundation—ld Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> + I umber <br /> SEEPAGE PITS l I—Dept -..— .. - --. Size—..-_ .� <br /> Property Line <br /> SUMPS >r Distance to nearest:. Well Foundation p Y <br /> DISPOSAL PONDS ❑ , } <br /> I hereby certify that I have prepared this application and that the work will be done-in 5_accordance_with San Joaquin county-ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District, p it i <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work,for which this ermit 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;6b*ontracting signature <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued; I sho'll employ persons su5jectao workman's compensa <br /> tion laws of California." <br /> 4 The applicant mu call for requi d inspections. Complete drawing on reverse psi <br /> Signed X — -- - <br /> Title:_. - Jr� Date:O p <br /> FOR DEPARTMENT USE ONLY <br /> >� � Date•�"Z I T�y Area , <br /> Application Accepted by q t <br /> Pit or Grout Inspection'by <br /> Date Final Inspection b ��-- Date f `V <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 11Tracy 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 CK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> (NFO <br /> +.EH 13-24(REV.t i n sl <br /> EH 14-28 <br />