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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (� Q PtA, r (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 /> l <br /> Joh Address 5 - City Itot Size PM ± <br /> I <br /> Owner's Nam Address – Phone <br /> Phone <br /> Contractor' Address r dos License NoI <br /> TYPE OF'WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �I <br /> `PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Wel! Excavation Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom' ❑ Manteca <br /> DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications S <br /> f'1 Public <br /> Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth_ nI I Eastern Sur a Seal Installed by - �r <br /> Repair Work Done A Type of Pump � H,P• State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 <br /> Depth Filler Material (Below 50') -- l <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION I 1 [No 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 Q <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 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth \Size Number ' <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ' <br /> 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 wofkman'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." 1,111 <br /> The appli st cal! for all required 'nspectio Compl drawing on'r a side. <br /> Signed X <br /> Title: Date <br /> : � <br /> OR DEPARTMENT USE ONLY91, 00 <br /> Application Accepted by date �� Area <br /> s <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date/ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 C1 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> CK 9FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> rt INFO �j `{,� (�/'�j �,p f7 <br /> ♦ EH 13-24(REV.FiX51 .S �Y, P-10 - J <br /> EH 14-26 V _ <br />