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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELT.01`4'A'1 E., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> Job Address Cit Size PM <br /> Owner's Name ddress Phone — <br /> r -. L dress df­ License Nolk23 B.Phone <br /> Contract <br /> t I�TYPE OF WELL/PUMP: NE 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 /> El Industrial 11 Open Bottom 171 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I71 Public F1 Other F Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth I I asternur rface Seal fnstalled by <br /> G <br /> Repair Work Done C�Type of Pump _.�_ H.P, State Work Done <br /> A It <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 t <br /> Depth Filler Material (Below 50') v` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 D-ESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other ) � W <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. CuMpartrru is <br /> PKG. TREATMENT PLT. ❑ MetYi'or1 gf;bisosal ' <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE- ❑ 'No.-&Length of lines - _ - -- -Total lengthlsize - - - <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number J <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line �! <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulation the San Joaquin Local Health D�trict. <br /> Home owner tensed a is 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 rson in suchm nner as to become subia workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies t following:"I ca y that in th rforma a the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion law of Calif nia." <br /> The a licant mu t c all req a ompl to d wing o r e <br /> Signed Title: — Data: <br /> { FOR DEPARTMENT USE ONLY <br /> Application Accepted by `'___.-1� Date A e �{ <br /> Pit or Grout Inspection by Data Final Inspection by <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 CASH RECEIVED BY DATE kPERM::]IT NO. <br /> INFO <br /> + EH 13-24(REV.1/95) <br /> EH 14-26 <br />