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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 <br /> (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 Ryles and Regulations of the San Joaquin <br /> Local Health District. /� <br /> Job Address - k a �'i D A City D Lot Size PM <br /> Owner's Name � � ®� �` 1 Address Phone <br /> 1d�ac£or � ®C ddress f f X License N .. Phone �` / Q <br /> TYPE OF WELL/PUMP: NE.W WELL ❑ WELLEPLACEMENT EI DESTRUCTION El <br /> PUMP INSTALLATION)( S�;�EM REPAIR ❑ OTHER ❑ <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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> XDornestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 0 <br /> ❑ Irrigation ---Approx. Depth [I Eastern Syrac Seal Installed by .0 <br /> Repair Work'Done C1 TypeofPump 41 ZJ H.P. JJ State Work Done f L <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is rh1 <br /> available within 200 feet.) 1 <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 /> i <br /> LE/ACHING LINE El No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ 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 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."Contractors 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 m I o Ire d inspections. Complete drawing on res. std <br /> - f aQ <br /> Signed Title: _ t�711 T� To �— Date: <br /> FO EPART ENT USE ONLY a <br /> Application Accepted by =+ Date Area <br /> Pit or Grout Inspection by ate 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.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMITNO. <br /> iNFO <br /> CASH <br /> +EH13-24(REV.I/er) <br /> EH 1426 <br />