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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA p p►`r Ep <br /> !° <br /> .—Telephone (209) 466-6781 AGe1 <br /> V <br /> 1PERMIT EXPIRES 7 YEAR FROM DATE ISSUED R <br /> (Complete in Triplicate) 6Ais <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an Satsq*uin <br /> Local Health District. <br /> Job Address <br /> ' City Lot Size PM <br /> dwner's Name 4��� Address Phone <br /> i <br /> Contractor Addressl e rLicense No t�2O 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 r ' DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE'WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 111 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> .JrDomestic/Private—❑ Gravel Pack— ---LD Tracy 4• -�- ��-Type of-Casing - <br /> Specifications <br /> ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx., Depth ❑ Eastern Surface Seal Installed by <br /> I' 1 State ark Done <br /> Repair Work Done It Type of Pump__ H.P. t <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'} ——� <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L) REPAIR/ADDITION C1DESTRUCTION El (No septic system permitted if public sewer is <br /> S /,# available within 200 feet.} <br /> Installation will serve: Residence '! Commercial— Other <br /> J <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines 3 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS EIDepth } Size Number <br /> SUMPS .❑ Distance to nearest: _Well Foundation Property Line � <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this-application arid 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•thaYin 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 /> Theapplicant ust I all required inspections. Complete drawing on r erse side. <br /> I� Signed X _ Title: Date: <br /> FOR PARTME T USE ONLY <br /> Application Accepted by <br /> It � Date ��Fl �� Area <br /> t `p? —y <br /> } Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: f ° <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 QCASH <br /> C RECEIVED BY DATE PERMIT NO. <br /> INFO y/�y �. <br /> + EH 13-24(REV.7/95) L(' <br /> EH 14.28 <br />