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APPLICATION FOR PERMIT <br /> f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 andlor 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 /> / �� � 1 _ City Lot Size PM <br /> Job Address, { <br /> C. Address � � <br /> Owner's Name ,pO Phone- <br /> Contracto ��eS,�C �'L Address � 1License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT-0. DESTRUCTION ❑ } <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ + OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FILO. PROP. LINE <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 /> ('I Public Ll Other n Delta Depth of Grout Seal Type of Grout <br /> --- <br /> I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by - <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 I <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION {.I REPAIR/ADDITION DESTRUCTION I i INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth .--- <br /> SEPTIC TANK ff--Type/Mfg Capacity No. Compartments <br /> _PKG...TREATMENT PLT. ❑ -..- - Method of Disposal <br /> Distance to nearest: Well Foundation Property Line V ' <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to.rlearest:_ . Welly Foundation Property Line <br /> n. ('� <br /> SEEPAGE PITS I'] Depth Size Number Y <br /> SUMPS Ll 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: 'A 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 mu70 <br /> Call for all required ins s. Complete drawing on r versa side. . <br /> Signed Title: Date: <br /> k Data' <br /> _ { 4 <br /> FOR ARTMENT USE ONLY <br /> Application Accepted by Date _ Area <br /> Pit or Grout Inspection by Date Final Inspection b --- - -- Dat <br /> Additional Comments: <br /> 0 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 I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO/ CASH / <br /> +EH 13-241REV76 <br /> EH <br /> �4L7� / ©• Q� - �••-"> ��� -���"-1 <br /> EH 14-26 <br />