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APPLICATION FOR PERMIT <br /> �s <br /> SAN JOAQUIN LOCACHEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., 8TOCKTON, 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 fora 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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address D <br /> IL City Lat Size PM <br /> Owner'sName Address 1 — Phone T <br /> Contractor Address <br /> License No. Phone <br />' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR1 , OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES'' <br /> E <br /> . .�._ ,DISPOSAL FLD. PROP. LINE <br /> FOUN DATION'"""'"" "'"AGRICULT0RE 1NELL"•'"'"" " OTHER WELL' PITS%SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation T pia. of Well Casing <br /> _.Fr Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications _ <br /> D.Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> i <br /> Ll Irrigation _Approx. De th ❑ Eastern Surface Seal Installedib <br /> Repair Work Done ❑ Type of Pump ' µP. <br /> -'�-° ,State Work 010pone- <br /> El Destruction Well Diameter Sealing Material (top 50'1 ' ,,.y,.z " <br /> Depth Filler Material (Below 50') 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of livingunits: ' %, i <br /> Number of bedrooms F <br /> Character of soil to a depth of'31feet: j <br /> { Water table depth <br /> El <br /> SEPTIC TANK Type�Mfg I ` <br /> .�}_Capacity j F_s' No. Compartments _ C <br /> PKG. TREATMENT PLT. CD "' .� <br /> � �'`` Method of Disposal � I <br /> Distance to nearest: Well : Foundation EZ,,.,property Line <br /> 5 J <br /> LEACHING LINE ❑ No. & Length of fines " -V <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well__� Foundation, Property Line <br /> 4 j <br /> SEEPAGE PITS ❑ Depth Size Number <br /> ,SUMPS ❑, Distance to nearest:_.-e Well_ --_Foundation d Property.-Line- .. - <br /> DISPOSAL PONDS s ❑ �- <br /> f � <br /> I 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 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 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mAist call f equired inspections. Complete drawing'on r verse side. <br /> Signed s <br /> Title " '� _ Date: <br /> FOR DEPARTMENT USE ONLV;> <br /> Application Accepted by Li`� � t' 3 —• � a/_ <br /> Date Area <br /> Pit or Grout inspection by Date Final Inspection by- Date <br /> _Additional Comments: L <br /> ❑ Stk 466-6761 ❑ Lodi 369-36211 © 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 <br /> INFO CASH RECEIVED BY PERMIT'NO. <br /> P <br /> + EH 1426(REV.i/e5) PDATE. <br /> � <br />