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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 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. i <br /> Job Address ` City t%A Lot Size In J,2elm <br /> Owner's Name' Address Phone <br /> Contractor's Name <br /> License No. S I LO INPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION C1 SYSTEM REPAIR ❑ 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 ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia, of Well Casing <br /> ❑ Domestic/PTivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public El Other ^❑ Delta I Depth of Grout Seal Type of Grout <br /> ❑ Irrigation Approx.,Depth k❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump I H.P. w State Work Done p <br /> WelI;Destruction'r`-❑ Well Diameter # +Sealing.Material (top 501 v s <br /> Depth 1 Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,Ilj]_JR&'AIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> t t available within 200 feet.) Z. <br /> ; <br /> Installation wilkserve: Re 'dance$-�mmercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feed z � Water table depth <br /> SEPTIC TANK= ❑ Type/Mfg Capacity I(Ci No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of repose) <br /> 1 Distance to nearest:';, Wei IA " Foundation 425 Property Line .� <br /> LEACHING,LINE € to-llo'_& Length of lines ZI RT" 4x Total­leitgth/size <br /> I FILTER BED ❑ Distance to nearest: Well Foundation .� Property r UnCe: <br /> t SEEPAGE PITS ❑ Depth Size` t JAI" 7-.J/OJ .Number I" <br /> SUMPS ;; ❑ 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 beAcine 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 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 Cal-ifornia." Contractor's hiring or sub-contracting.signature <br /> cert! 'as the following: "I c ify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa ; <br /> tion la f California." 3 <br /> The applican II for all qu' d ins ions. mp to drawing o reverse side. s <br /> Signed tle: I Dated <br /> - FOR DEPARTMENT USE ONLY r/ <br /> � — Area ( 2, <br /> Application Accepted;;iby Date # <br /> Pit or Grout Inspectior;'iby Dae Final Inspection by- �- {Date <br /> Additional Comments: <br /> i 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638b <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 CK# RECEIVED BY DATE PERMIT'NO. <br /> INFO CJA,S/H <br /> +EH' 3-24(REV.10183) <br /> EH 1428 <br />