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APPLICATION FOR PERMIT t <br /> r- 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 rpt <br /> (Complete in Triplicate) ± mo <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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> �., of Size <br /> Job Address — City PM <br /> Owner's Nam Address - <br /> L�sPLtf Phone 4613 _91%02 <br /> Contractor - Address License No. Phone_ ) t <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .— <br /> FOUNDATION <br /> INE .FOUNDATION AGRICULTURE WELL OTHER-WELt PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom 1-1MantecaDia. of Well Excavation Dia. f Well Casing <br /> El Domestic/Private LJ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ OtFier ❑ Delta Depth of Grout $eal Type of Grout <br /> El Irrigation _�pprox. Depth ❑ Eastern Surface SeaP Installed by <br /> Repair Work Done El Type of Pump H.P. State Work Done <br /> Well Destruction ❑ <br /> Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material l8elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) O <br /> I Installation will serve: Residence— CommercialOther <br /> j Number of living units: Number of bedrooms �-(� , <br /> I Character of soil to a leplh of 3 feet: Water table depth 1 , <br /> P <br /> SEPTIC TANK Type/Mfg Capacity o. 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 /> i <br /> r FILTER BED © Distance to nearest: Well Foundation Property Line <br /> l <br /> SEEPAGE PITS ❑ Depth Size Number <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 be done in accordance with San Joaquin county ordinances, state laws, and . <br /> rules and regulations of the San Joaquin Local Health District. <br /> F 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 /> j 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: "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." <br /> I The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Title: ON& Date: <br /> r l'' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspectio Date Final Inspection by Date s� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 I❑ 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 /> FEEAMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. <br /> INFO - <br /> + EH 13-24{REV.t/n sy Off ` �I � / �� <br /> EH 14-2e <br /> Ci <br />