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1 APPLICATION FOR PERMIT <br /> 1 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 <br /> (Complete in Triplicate).,R <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. 1662 for well/pump and the:Rules and Regulations of the San Joaquin <br /> Local Health District. . <br /> Jab Address �`�p City Lot Size PM <br /> Owner's Na Address - Phoneme <br /> , <br /> Contractor's Name /�� -�� License No. Phone ' <br /> TYPE OF WELL/PUMP: NEWWELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR m" OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKS I SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION:I AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> wbomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depthj."El Eastern Surface:Seal Installed by <br /> Repair Work Done EJType of Pump H: 1 .° Stale Work Done Q <br /> Well Destruction ❑ Well Diameter Sealing Material Itop'�50'•I_ <br /> Depth �-Eller Material iBelow50'I <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:' 14""'"'"' . """ � - "%Ater table depth <br /> SEPTIC TANK ❑ Type/Mfg - �-. --' -4-Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ? Method of Disposal n <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ' Total length/size <br /> FILTER BED ❑ Distance tonearest: Well Foundation Property Line h <br /> SEEPAGE PITS ❑ Depth it Size I 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 /> 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." 't1 <br /> 1 g <br /> The applicantsust c II f ll required inspections. Complete drawing'on reverse side. <br /> Signed Title: Date: J � <br /> FO DEPARTMENT USE ONLY <br /> `` <br /> Application Accepted byC!" Date _ Area <br /> Pit or Grout Inspection by Date Final ins pe ction bc° {r `"�'Date <br /> y <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 F{ RECEIVED BY DATE PERMIT"NO.' <br /> INFO Q <br /> + EH 13-24(REV.10183) <br /> EH 14-28 <br />