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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> r PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> t F (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 cS <br /> City Lot Size , PM <br /> I Owner's Name <br /> � Address iQ6 <br />` Phone <br /> Contractor. ; <br /> Address -License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ —Phone <br />- WELL-.REPLACEMENT L]' DESTRUCTION L7 <br /> PUMP INSTALLATION ❑ r SYSTEM REPAIR ❑ ~A <br /> 'DISTANCE TO-NEAR EST:"-S EPTIC"TANK""""„`"^` �- � �. OTHER Q <br /> SEWER�L`lNES` ISPDSAL`FLD—PROP'"L"INE"7='­---•-- -- <br /> FOUNDATION A RICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A A CON UCTION SPECIFICATIONS <br /> ❑ Industrial Q.Open Bottom ❑ Manteca r <br /> 1 . - . of Well Excavation , <br /> ❑ Domestic/Private `<�'❑ Gravel Pack1 Dia. of Well Casing <br /> ❑Tracy <br /> :,,� ype of Casirig <br /> i'i Public ❑ Other 1 3 o Specifications <br /> n Delta 'De of-Grout Seal <br /> I Irrigation \, h Type of Grout <br /> Approx. Depth I tern Surfac eal Installed by <br /> Repair Work Done; ,O >�.Type of Pump H P _ <br /> Well Destruction State Work Done <br /> ❑ Well Diameter +Sealing.Material (top 50't <br /> Depth Filler Material (Below-50') h\ <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION II DESTRUCTION (No septic system permitted if public sewer is <br /> �. available within 200 feet.) j <br /> installation will serve: Residence Commercial i Other k i <br /> Number of living units: - Number of bedrooms h <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg I <br /> Water table depth <br /> Capacity No. Compartments <br /> PKG, TREATMENT PLT. 0f <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> I Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BEDTotal length/size i <br /> Cl Distance to nearest: Well Foundation <br /> � Property Line <br /> SEEPAGE PITS I ) Depth' It <br /> Size — Number <br /> SUMPS LI Distance to'nearest: Well <br /> DISPOSAL PONDS ❑ Foundation Property Line r ! <br /> t <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: <br /> employ any person in such manner as to become subject to woman's comthat <br /> pensation lawsOof Califorrnia." Cont actnce of the work foror s tch hiringthis <br /> oP ub-contract nglsigall o <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." t <br /> The applic It must cal a r quir d if ictions. Complete drawing on reverse side. ` <br /> h <br /> Signed X Title: // <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by , <br /> Date Area <br /> Pit or Grout Inspection by Data <br /> Final Inspection by Date � 1 <br /> Additional Comments: ` <br /> ❑ Stk 466-6781 ❑ Lodi -3621 .1 ❑ Manteca 623-7104 ❑ Tracy 835-fi385 + <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 t <br /> r 4 <br /> FEE <br /> EH 13.24(REV,5 AMOUNT DUE AMOUNT REMf7TED <br /> INFO CASH RECEIVED BY jDATEPERMIT-NO. :1 <br /> i x s!EH)4.28 �� <br />