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APPLICATION FOR PERMIT ` " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 x1 , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) r^, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein ed. 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. 1 r . <br /> Job Address�� 0 'r- 7 -City�: Lot Size PM <br /> Owner's Name Address ;Yu `� Phone <br /> Contracto '-[- -�+� Address /6 Cr'30Lticense No ��Z Phon+�� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ID <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ['l Public D Other D Delta Depth of Grout Sea] Type of Grout <br /> € 1 Irrigation --Approx. Depth I 1 Eastern j Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1, REPAIR/ADDITION LI DESTRUCTION I I (No septic system permitted if public sewer is 1 <br /> available within 200 feet.) <br /> Installation will serve: Residence Comm.ercial_ 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 D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 111Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i LEACHING LINE D No. & Length of lines Total length/size <br /> l , <br /> FILTER BED E1 Distance to nearest: Well Foundation Property Line <br /> j) <br /> SEEPAGE PITS I 1 Depth I Size _ Number <br /> I SUMPS D Distance' to nearest: Well Foundation-_. Property Line <br /> t DISPOSAL PONDS ❑ I I <br />{ I hereby certify that I have prepared tAis 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 /> empfay any person in such manner as to become subject to workman's compensation taws 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 /> 1 The applicant mus II for all.re wired inspections. Complete drawing_o reverse side. °" " <br /> Signed Title:L Date:to 1 `� <br /> ' FOR DEPART SE ONLY <br /> Application Accepted by � Date r Area <br /> Pit or Grout Inspection by Date Final Inspection by< Date <br /> t �! <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 835-6385 <br /> k Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I t <br /> k <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIVNO. <br /> INFO CASH ]yJ <br /> +.EH 13.24[REV.1 i H 51 (,(J <br /> EH 14-28 <br />