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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 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ve� <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 r' �} '� <br /> City of Size PM <br /> Owner's Name Address — <br /> Phone <br /> Contractor Atldress � � r License No �; l0?Phone -1f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTiM REPAIR ❑ OTHER ie <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ._r DISPOSAL FLD. PROP. LINE <br /> E <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom _JX.•,❑ Manteca'_,t Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 17 " <br /> Gravel Pack ' C1 Tracy Type of Casing �Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Dep.th <br /> -- p Eastern Surface Seal Installed by <br /> Repair Work Done )t Type of Pump wd6 H.P.E Stale Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is 9 <br /> f 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. ❑ Jt Method of Disposal <br /> y <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE_ ❑ No. & Length of lines Total length/size <br /> FILTER BED - ❑ Distance to nearest: Well Foundation Property Line ` <br /> SEEPAGE PITS 5 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ .l <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 compensationlaws 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 per,mit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> . F <br /> The applicant must call for required inspections. Complete drawing on reverse side. <br /> a <br /> Signed �^�' Title: Date: <br /> FOR DEPARTMENT USE ONLY J ! i. <br /> Application Accepted by �� Date + Area /o� <br /> j <br /> f. <br /> Pit or Grout Inspection by Date_ Final-Inspection by_/ iC�� ' _ Dated <br /> Additional Comments: k <br /> ❑ Stk 466-6781 11 Lodi 369-3621 ❑ Manteca 823-71134 '❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 t Hazehon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> n C— <br /> + EH 1324 fREV.1/a 5) D03 D <br /> 1 1 <br /> EH 1426 '�` } <br /> l <br />