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APPLICATION FOR PERMIT <br /> V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 �&o VAL.. <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 Ordnance 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��- r C ° - 1 •`mac.-. City!'_;_, ,Lot SizesPM <br /> Dwilers Name '_✓ f"' �/fie.. VAddress � CZ '-1/-4 <br /> r 'F Phone <br /> . `.P !.+'4. r . <br /> PJ <br /> Contractor - Address License No- Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L! DISPOSAL PROP. LINE <br /> FOUNDATION AGRICULTUR ELL OT LL- — PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS UCT PECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. Excavation _- Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casi Specifications <br /> ❑ Public ❑ Other �Delta Depth of Grout al Type of Grout <br /> ❑ Irrigation --Approx. Depth Surface Seal install by <br /> Repair Work Done ❑ Type of Pump . . State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'I <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO {No septic system permitted if public sewer is <br /> available within 200 feet.l <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: onj r t Water table depth <br /> SEPTIC TANK X Type/Mfg Capacity mpartments <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 Foundation i Property Line <br /> SEEPAGE PITS ❑ epth Size 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 fce"nsed want'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 n In sucli manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the fol owlr-lii <br /> that int performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of CTh licanfrrlLt' ' spections. 5mplete drawing on rave side. <br /> Signed Title: Date: <br /> , FOR DEPARTMENT USE ONLY <br /> Application Accepted by i Date C? Q Area <br /> Pit or Grout Inspection b Date Final Inspection by � Date Z� <br /> Additional Comments: <br /> ❑ Stk 456-6781 ❑ 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 RECEIVED BY DATE PERMIT'NO. <br /> INFO CA <br /> + Eli 1321(REV.1/e 5) <br /> EH 1125 <br />