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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE.,.STOCKTON, CA <br /> -Telephone-{209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED f <br /> f <br /> (Complete in Triplicate)i <br /> Application is hereby made to the San Joaquin Local Health District fora 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 /> .. <br /> Job Address _ City /� Lot Size���'"�.�"� PM <br /> Owner's Name /P� ��� Address Y- v < Phone <br /> ContractorY` — Address <br /> License No. 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 /> r� INTENDED,U.SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> 'V Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation E" —Approx. Depth ❑ Eastern Surface Seal Installed by 7 <br /> Repair Work Done, ❑ Type of Pump H.P. State Work Done fir/ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') J <br /> Depth Filler Material (Below 50') �) <br /> TYPE OF SEPTIC-WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> • - available within 200 feet.) <br /> Insiallation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms f i <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. ❑ 1 Method of Disposal <br /> f i <br /> Distance to nearest: Well Foundation Property Line <br /> ACHING LI No: & Length of lines Total'Iength/size ry <br /> FILTER BED i❑' Distance to nearest: Well Foundation Property Line f <br /> SEEPAGE PITS EJDepih,_S2 5: Size t• Number <br /> S P ❑ Di a e'to-nearest: ► Well F undation Property Line <br /> DISPOSAL PONDS. ❑ <br /> I hereby.certify,that Phaye prepared ifiis application and that the work'will be dotie"inaccordance 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:-'1 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_cdmpensation 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 thisp4iiAif is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." #"al y f <br /> The appItmust tail for req it inspe tions. C plate drawing onreverseside.Signed W� Title: I c7 �7 <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by "Oy!z Date / �°7w! � <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection Date <br /> t <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca A23-7104' �,l�0.Tracy 835-6385 r <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-, CA 95201 <br /> LINO FEE AMOUNT DUE;ry4 'AMOUNT REMITTED C RECEIVED;B" DATE PERMIT NO. <br /> '+ EH 13-241REV.t"/n51 "� <br /> EH 14.28 <br />