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APPLICATION FOR PERMIT a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E..HAZE0ON 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 <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 /> IT <br /> Job Address Ci of Size PM <br /> Owner's Name Lss Address � <br /> ^� rPhone <br /> J Contractor 1 `Address 0 D L I License No. r )— ^r7-3 Phone Z <br /> TYPE OF WELL/PUMP: WEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 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 /> +t '60—.estic/Private _ ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other s ❑ Delta Depth of Grout Seal Type of Grout <br /> El Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Q�-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 ❑ REPAIR/ADDITION ❑ DESTRUCTION EJ (No septic system permitted if public sewer is <br /> available within 200 feet.} <br /> j 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 /> 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 y4Foundation Property Line <br /> i <br /> SEEPAGE PITS ❑ Depth size Number T <br /> SUMPS ❑ Distance to nearest: Well Foundation Ptoperty Line <br /> DISPOSAL PONDS ❑ <br /> 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 lice 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 pars in such ma er as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the f owing:-I certify hat in the pert mance the work for 1whichnthis permit i ued, I shall employ persons subject to workman's compensa- <br /> tion laws o California " <br /> The appli ant must ca II mqui rawingerse <br /> Signed /�� Title: <br /> + FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date A Area 1 <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 85201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.5 i a s) -7� <br /> EH 1428 <br />