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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 1 YEAR FROM DATE ISSUED c� <br /> (Complete in Triplicate) ' <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install the �erel rirOn is <br /> u n ' <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for welllpump and t es <br /> r+ �f <br /> Local Health District. a k,'rt' �I <br /> .3 Wil. IC �7 c/ . City Lot Si <br /> Job Address Oj <br /> •�• � �`�O� <br /> Owner's Name Address <br /> ContractorOF <br /> ( r Address S �� a © •License No. Phone <br /> I TYPE OF WELL/PUMP: NWELL .�; WELL REPLACEMENT ❑ DESTRUCTION ❑ vA <br /> PUMP INSTALLATION LlSYSTEM REPAIR 11OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �D�� SEWER LINES DISPOSAL FLD. f PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> X INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (0�� <br /> T of Cin Specifications s <br /> �(Domestic/Private )(Gravel Pack Tracy y Casing— T of Grout <br /> I <br /> El Public ❑ Other ❑ Delta Depth of Grout Seal YPe <br /> EJIrrigation' ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ _ .Type of Pump H.P. State Work Dore <br /> Well Destruction ❑ Well Diameter —�_— Sealing Material (top 50'1 x <br /> Depth_� �s Filler Material (Below 501 <br /> sysm permit <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ alvailabllesept3within 200 feet.)ed if public sewer is <br /> Installation - serve: Residence_ Commercial_ Other <br /> - Number of living units: f bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK.~' ❑ Type/Mfg city No. Compartments <br /> -- PKG. TREATMENT PLT. ❑ Method of Disposal <br /> �-" Distance to nearest: Well Foundation Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> ILTER-13ED ElDistance to nearest: Well Foundation Property Line <br /> f <br /> I <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS a.1 ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL.PONDS• ❑ <br /> -hereby that have prepared this application and that the work will be done in accordance-with S8n Joaquin county ordinances, state laws, and�� <br /> ( <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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California.' <br /> The applicamu call for all required i spections. Complete drawing on rerer`se�side. <br /> Signed <br /> Title: — r + Date- � —: <br /> of F R PARTMENT USE ONLY <br /> 1 <br /> f <br /> � <br /> / C�-�-� Date � Area <br /> Application Accepted by j <br /> Pit or rou inspection by' Date b �& Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> +EH 13-24(REV.1/6 5) <br /> EH 14-2a <br />