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I <br /> �._ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., .STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heteby 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 10 (pLZe City Lot Size PM <br /> Job Address _ <br /> Owner's Name rra If Address5/A Phone <br /> Contractor 5 � Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> Ptils�P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC T SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ _ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUC ONS <br /> ❑ Industrial ❑ Open Bottom ❑ Ma Di f Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private' ❑ Gravel P ❑ Tracy Type of ng Specifications <br /> fl Public ther ❑ Delta Depth of Grout al Type of Grout <br /> I I Irrigation _.-Approx. Depth I i Eastern Surface Seal Installe <br /> Repair ark Done ❑ Type of Pump H.P. Sta a Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION €1 REPAIR/ADDITION I 1 DESTRUCTION (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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> u <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Wsttict. <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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: _ <br /> FOR DEPARTMENT USE ONLY ^ M <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by _._._� Final I e ion by ata <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 AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. <br /> INFO CASH / ^EH 13-24 IHEV.v/n 51 `�� '� �� 17-2q4.1 KGEH 14-26 �3—� <br />