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's APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED 0 PAP,D <br /> {Complete in Triplicate} A 6we­0'7- <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 welupump and the Rules and Regulations of the San Joaquin <br /> Local Health District. j <br /> Job Address City of Size LPM <br /> r <br /> Owner's Name Address e, Phone ��U <br /> i <br /> Contractor Address License No. Phone_ <br /> ,TYPE OF WELL./PUMP: WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE AI <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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> t'1 Public 141 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __Approx. Depth l I Eastern Surface Seal Installed by <br /> iRepair Work Done ,❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION)t<Mo septic system permitted if public sewer is <br /> available-within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> ti <br /> Number of living units: Number of bedrooms j <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 /> LEACHING LINE ❑ No. & Length of lines Total lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L-i 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." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work far which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must cal for all <br /> lrQrequired <br /> diinspections. Complete drawing on reverse side. <br /> Signed X i�� /�! Y/ f Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> /�/]���j�(,� �- <br /> Application Accepted by a - - Date 2s����)r��; Area <br /> Pit or Grout Inspection by Date Final Inspection byrr�e Date. <br /> Additional Comments: 46 �2���7/ <br /> ❑ Sik 466-6781 0 Lodi -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 ASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> tr p ,g <br /> + EH 13-24(REV.1/n h) �.! <br /> EH 14-28 "�J <br />