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1z <br /> b rs APPLICATION FOR PERMIT <br /> ,L <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r� <br /> tr 1 {_� �f <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ��'"t <br /> Telephone (209) 466-6781 ' <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applicatibri 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 /> Job Address 4 City L.Si�e PM <br /> -- <br /> Owner's !Name Address r Phone a 760 <br /> �j <br /> Contract �L7cense Nolb�Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM 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 CON STRUCTION.SPECIFICATIONS, <br /> ❑ Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1`1 Public ❑ Other Ci Delta Depth of Grout Seal Type of Grout--­ <br /> 11 <br /> rout11 Irrigation �_Approx. Depth_ l Eastern Su ace Seal Installed by - <br /> Repair Work Done Fro Type of Pump H.P. 1 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 U <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION l I (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. El , Method of Disposal <br /> Distance to nearest: Well Foundation Property_Lme <br /> LEACHING LINE ❑ No. & Length of tines Total length/"size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> k <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Cl 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 lic agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any on in suc anner as to b come su 'e t work an's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies i fallowing: "I c ify th in tIn o o the,wo k or which thi permit is issued, I shall employ persons subject to workman's compensa- <br /> tion la of Caiifornia." �^ <br /> The a plicant must c or ail r uire I ti s. rawing on e e <br /> Signed Title: Date: <br /> OR DE RTMENT USE ONLY / r� <br /> Application Accepted by Date 100 Area <br /> Pit or Grout Inspection by Date Final Inspection by �� Date -1 <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 REMITTED CAS RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24 1REV.1/H 51 <br /> EH 14-28 <br />