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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r I 1601'E:'HAZE"`TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> MI <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> j (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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> M Job Address <br /> g — City L'ot Size t u ` PM <br /> Owner's Name Address Address Phone <br /> / r License <br /> /'d�/ <br /> I Contractor ess - -- <br /> lTYPE OF WELL/PUMP: NEW WELL Z;— WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION V- SYSTEM REPAIR ❑. OTHER ❑ <br /> D� 7 �DISPOSAL FLD. PROP. LINE <br /> II DISTANCE TO NEAREST: SEPTIC TANK- � SEWER LINES � ^//�,. i <br /> FOUNDATION d AGRICULTURE WELL OTHER WELL GIS PITS/SUMPS/_5:1�/- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA `CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mantecay Dia. of Well Excavation C� Dia. of Well Casing <br /> mesticlPriJate vel Pack ❑ Tracy Type of/casing . �� Specifications , <br /> L1 Public <br /> ❑ Other ❑ Delta Depth of Grout Se Type of Grout 1 <br /> El Irrigation --Approx. Depth - ❑_Eastern : - rface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> t. Well Destruction ❑ Well Diameter SealingFMaterial.(top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION.❑:•,,,.DESTRUCTION F1 (No septic system permitted if public sewer is �7 <br /> 71 r �. •y available within 200 feet.) I f <br /> Installation will serve: Residence_ Commercial!`,.Other " <br /> Number of living units: Number of bedrooms <br /> ­ ,1 ` Water table depth <br /> Character of soil to a depth of 3 feet: w <br /> SEPTIC TANK ❑ Type/MfgCapacity. No. Compartments <br /> y 1 <br /> �) PKG. TREATMENT PLT. F-1 Method of Disposal <br /> q, Distance topearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines t. <br /> FILTER BED ❑ Dista ce to nearest: . Well Foundation Property Line <br /> I <br /> I , SEEPAGE PITS ❑aDepth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that:l 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 peison 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 si e. �r <br /> (/� Date: <br /> � Signed Title: �l� <br /> FOR DEPARTMENT USE ONLY 7� <br /> Application Accepted b Date Area <br /> j Pit or Grout Inspection by ate �'����7 Final Inspection by Y A. Date <br /> p I Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83x6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 9b201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> • INFO S� <br /> + EH 1324(REV. /s 5) 5 ., <br /> EH 14-2e t—J <br /> R h - - <br />