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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT J <br /> w�. 1601 E. H/AZE'�TON,AVE STOCKTON, CA <br /> .. Telephone (209) 466 6781 <br /> y � <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED APR <br /> � (Complete in Triplicate) �1�{ <br /> �M%RNAUU&T p�tidation is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insta I�i �m �11' San Joaquin <br /> � <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the ..?3 <br /> Local Health District. (] <br /> S �I� y�Y�IV1.r✓� o rze � � PM <br /> Cit <br /> Job Address lra <br /> Phone <br /> ddress <br /> Owner's Name , <br /> > p� Z License No. I1�L 3 I Phone J <br /> Contractor Nvw Address_i <br /> 5, ;.TYPE OF 1NELLlPUMP: NE WELL EJ REPLACEMENT ❑ DESTRUCTION LJ <br /> S SYSTEM REPAIR LJ DESTRUCTION <br /> El- - g PUMP INSTALLATION <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE;OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> d Industrial ❑ Open Bottdm ❑ Manteca Dia. of Well Excavation <br /> 1 ''.i Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> n Public <br /> Ci Other 1-1DeltaDepth of Grout Seal <br /> I I Irrigation —..Approx. Depth- i I Eastern Surface Seal Installed by <br /> Type of Pum H.P. State Work Done <br /> Repair Work Done (3TYP p <br /> Well Destruction 1-1W611diameter: <br /> Sealing Material itop 50'1 <br /> t Depth �t Filler Material (Below 501 <br />{ . (No <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATIaN I.I REPAIR/ADDITION l I DESTRUCTION l 1 ave septic system permitted if;fic, wer is <br /> available within 200 feeLl <br /> 5, Installation will serve: Residences Commercial <br /> Other ! "Number of living units: NumbWof bedrooms Water table depthCharacter of soil to a depth�of 3.feet: No. Compartments#:.;. CapacitySEPTIC TANK ❑ TVpelMfgMethod of Disposal / <br /> ' <br /> PKG. TREATMENT PLT. ❑ <br /> lt � Property Line t {' <br /> • " D'istance'to nearest: Well Foundation ' P <br /> r y Total length/size <br /> t LEACHING LINE 0 No. & Length of lines Property Line <br /> FILTER BED ❑} Distance to nearest: Well Foundation P Y <br /> t Number <br /> SEEPAGE PITS I I Depth n ; Size Property Line <br /> ' •.testi.. 1 <br /> SUMPS Ll Distance to.nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> ' r <br /> I is application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I spared th <br /> rules and re, s of the Sa Joaquin Local Health District. <br /> Home owne r licensed agent's signature'certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not <br /> F employ an person in such arias to become subje o workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies t personfollowi : "i c y that s he r e the work for which this permit is iss ed, I shall employ persons subject to workman's compensa- <br /> tion laws f Calif i ' <br /> F <br /> The appli ant st call f all re ire p drawing on r <br /> id.. <br /> r"4 r <br /> Title: Date <br /> Signed X : <br /> F DE ENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> t Date <br /> Pit or Grout inspection by - Date Final Inspection b <br /> k Additional Comments: a <br /> I ❑ 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 /> CK RECEIVED BY <br /> INFO DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> +.EH 13-241REV.5/14 51 <br /> EH 1426 r <br />