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APPLICATION FOR PERMIT <br /> .,_.F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T 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. This application is j <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1652 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District- <br /> Job Address � �� City ��� of Size PM <br /> � r <br /> Owner's Name Address Phone <br /> r <br /> �•H <br /> Contractor Address License No.a—"' Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 3 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> D15TANCE'TO'NEAREST'8LPTIC'TANK " " ­SEWER LINES – - -DISPOSAL;FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL Zf OTHER WELL PITS/SUMPS _ <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA ONSTR TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ElManteca Dirt. of ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other F] Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ,Installation will serve: Residence Commercial_ Other i <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 /> PKC. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nea're`st:""' Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of fines Total length/size <br /> FILTER SED r ❑ ;Distance to nearest: Well ^� w Foundation y Property Line <br /> SEEPAGE PITS � ::�•.1'4 I }Depth Size Number <br /> SUMPS--- L�4Distance-to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - 41 <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. j <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 /> c6rtifies 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 /> The applicant must call for II req d ins ctions17C. <br /> C.mplete-`drawing on reverse side. <br /> Signed X L S Title: �!�'!��!s Date: <br /> FOR DEPARTMENT USE ONLY <br /> % <br /> Application Accepted by Date Area <br /> g <br /> Pit or Grout Inspection by to Final In pe ti n by DatVf/�/' <br /> Additionai Comments: v <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 v <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo> 2009, Stk., CA 95201 <br /> w �, EE' <br /> E AMOUNT DUE AMOUNT REMITTED �C RECEIVED.BY DATE.r PERMIT NO. M' <br /> t INfO c ASH, , <br /> + ID EH 13-24(REV.r i x al <br /> EH 14-29 _ .l y 2_J <br /> D 2-7-U.F7 U�'/7—3WtJn <br /> � <br />