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APPLICATION FOR PERMIT <br /> If; JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T Ofd AVE., STOCKTON, CA 1 <br /> Telephone (209) 466-6781 <br /> t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 Rules and Regulations of the San Joaquin <br /> Local Health District. il F <br /> C <br /> Job Address -[it Lot Size PM C <br /> r _ <br /> a2� <br /> Owner's Name Address Phone <br /> Contracto ' Address .License NoPhon �� 1 <br /> TYPE OF WELL/PUMP: NEW.WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR l� 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 CONSTRUCTION SPECIFICATIONS <br /> ❑�Industrial a ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 5?<.o esticIPrivate ❑ Gravel Paclk 0 racy Type of Casing Specifications <br /> [I Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation � ..Appfox: Dept l Eastern Since Seal Installed by <br /> L� Type of Pum r� H.P. /._-l�_ State Work Don } � 4 <br /> Repair Work Done yp p <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION l ) DESTRUCTION l I (No septic system permitted if public sewer is <br /> >� available within 200 feet.) <br /> Installation will serve: Residence' Commercial— Other ` <br /> r <br /> + <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:'1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal t <br /> Distance to nearest: Well Foundation Property.Line t1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS I I Depth I Size_ Number <br /> SUMPS L� Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 Di§trict. <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 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on <br /> reverse side. <br /> Signed X Title: �/I!��y1 Date:'1112 <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> Application Accepted by + Date /Y4 Area <br /> Pit or Grout Inspection by Da Final Inspection by <br /> Date1OL� I <br /> t <br /> Additional Comments: - <br /> ❑ Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 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 DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +AH 13-24(REV.1/A 5) �t--�- ( �/" 1 />► I <br /> EH 14-26 <br /> _ % 1, <br />