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f APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 'S <br /> T R % C. <br /> s 1601 E. HAZE I ON AVE., STOCKTON, CA A) ! a: ' <br /> Telephone (209) 466-6781 'I <br /> PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> i <br /> (Complete in Triplicate) "'` ZJ. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th'e,wo�R`Fierein des rib dThis application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rulees an'd Regulations of'fhe San Joaquin <br /> Local Health District. t- .,,. . <br /> I <br /> Job Address r <br /> City A420Lot Size ply <br /> Owner's Name Address UrJJ <br /> r Phone <br /> I Contractor Address(e / / <br /> License N& � Phone h .2 <br /> TYPE OF WELL/PUMP: ANEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ �- SYSTEM REPAIR R ` OTHER Cl <br /> f 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 /> ❑ Domestic/Private. -EIGravel.Pack—.—C]-,Tracy-_Y �, ..-Type of Casing _ Specifications <br /> I I 1 Public n Other- .. F pelta Depth of Grout Seat v <br /> r Type of Grout _ <br /> If}�Irrigation —_Approxi Dept I Ie Eastern Surface Seal Installed by <br /> Repair Work Done E�T' Type of PumH.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth _.. Filler Material (Below 501 # <br /> -TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR'/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.I <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 fable depth i <br /> SEPTIC TANK ❑ Type/Mfg' <br /> PKG. TREATMENT PLT. Capacity <br /> No. Compartments <br /> . El � ,-; <br /> Method of Disposal <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 <br /> . � Property Line <br /> i <br /> SEEPAGE PITS I I Depth - Size Number <br /> SUMPS Cl Distance to nearest: Well <br /> Foundation " <br /> Property Line <br /> DISPOSAL PONDS _LJ _ <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. I <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."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 shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call for all re wired inspections. Complete drawing on reverse side. <br /> Signed XX - { x . . 2 <br /> itle: Dater / <br /> • FOR PARTMENT USE ONLY I Y <br /> Application Accepted by Date <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by 1 <br /> Date AL&M <br /> Additional Comments: I <br /> 1-1 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 /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMI7'NO. <br /> + EH 13-24(REV iiHs) � <br /> EH 14-26 <br />