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G � APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT NUS <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA 4a�� <br /> Telephone (209) 466-6781 C La <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED INS <br /> ' <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. <br /> Job Address //Z ��` ` <br /> A � City L <br /> Lot Size _ PM <br /> Owner's a� XAfess= / 4 Pho <br /> CoTAddress License No. Phone <br /> TYPE-OF WELL/PUMP: NfW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK, SW <br /> EER LINES DISPOSAL FLD. PROP. LINE ? { <br /> " FOUNDATION - A ULTURE WELL OTHER WELL__!__2115/SUMPS v ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECT S <br /> ❑ Industrial LEJthe <br /> n Bottom ❑ Manteca Dia. of vation Dia. of Well Casing <br /> AL <br /> ❑ Domestic/Private vel Pack : ❑ Tracy a of Casing ' Specifications ^ <br /> ❑ Public r ❑ D Depth ofGrout Seal Type of Grout I fo❑ Irrigation' pprox_ D Eastern Surface Seal Installed by <br /> Repair Work Done ❑ ump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501It <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑, REPAIR/ADDITION ❑ DESTRUCTION (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 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> r ti, I <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 /> i <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: -Well Foundation Property Line <br /> DISPOSAL PONDS 0 i <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: "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." rfl, <br /> The a plicant mu call for all requir d inspections. omplete drawing.on reverse side. <br /> igned Title: "Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area LJ <br /> Pit or Grout Inspection b Date y Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ IiAiiii r""923-7104 '❑ Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IQINFO AMOUNT DUE AMOUNT REMITTED FEE CK CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH1&24(REV.i/H 5) 0c)EH <br /> I <br />