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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> 1601 E. HAZEL i 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 and/or install the work herein described. f th application is <br /> lations of th <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regue San Joaquin 1 <br /> Local Health District. t} Size M <br /> � rt <br /> 1 �i� CJ�u! TD/� /�R <br /> at <br /> City <br /> Job Address <br /> ��� C r ddress D r Phone <br /> Owner's Name 1 <br /> JI Address License No. Phone <br /> Contractor <br /> ONEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1TYPE F WELL/PUMP: <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES <br /> DISPOSAL FID. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL P <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION O.N S Dia. of Well Casing <br /> ❑ Industria! LJ Open Bottom (I Manteca ell Excavation ; <br /> of Casing Specifications <br /> ❑ Domestic/Private �-❑ Gravel PacType k ❑ ¢ <br /> FI Public <br /> ❑ Other Cl Delta Depth of Grout Seal Type of Grout - <br /> I 1 Irrigation _ ppro0 Depth I 1 Eastern Surface Seal Installed by <br /> ' <br /> H P State Work Done <br /> Repair Work Don Type of Pump <br /> Well D tion ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material [Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i] REPAIR/ LI DESTRUCTION available'c system withitem <br /> n 200 feetermrtled if public sewer is 0 <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms e table depth �� P <br /> Character of soil to a depth of 3 feet: <br /> Type/MfgCapacity No. Compartments <br /> 1 <br /> SEPTIC TANKi <br /> Method of Disposal <br /> PKG. TREATMENT PLT. i <br /> Distance to nearest: Well Foundation Property Line <br /> I LEACHING LINE ❑ No. & Length of lines Total length/size <br /> rProperty Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> SEEPAGE PITS 1 1 Depth Size Number <br /> i <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> f 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 /> } fy that in the performance of the work for which this permit issued. I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certiCalifornia." Contractors hiring <br /> employ any person in such manner as to become subject to workman's compensation laws ss c 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 /> Don laws of California." <br /> The applicant must call for all requ'ed ins ctions. Complete drawing an reverse side. <br /> Signed X <br /> Title: �'/ Date: <br /> f3R DEPARTMENT USE ONLY <br /> Date �wd �.'u---�-.— Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> I Date Final inspection by Date <br /> Additional Comments: <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 CASH CK 9 RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> Go Com . <br /> + EH 13-24(REV.1/R 5) —�0 r <br /> EH 14-2a <br />