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APPLICATION FOR PERMIT ��, ��► <br /> 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) <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 /> M"AJob Address City Lot Size PM <br /> Owner's Name d� V``�+ Address Phone <br /> Contractor's Name &" License No. 3/7',7 0 Phone <br /> I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ) OTHER Q <br /> DISTANCE TO NEAREST: SEPTIC TANK r' + SEWER LINES f�� 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic_/Private El Gravel Pack , ❑ Tracy Type of Casing Specifications o rt <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal °F Type of Grout ,! <br /> ❑-Irrigation~- ,... _.: ••_�_gpprox.-Depth ❑ Eastern- SSeal by <br /> Repair Work Done K Type of Pump ky�_ H.P. u ace State Work Done <br /> ►r �N <br /> Well Destruction ❑ Well Diameter — o Sealing Material atop 50'1 1 <br /> Depth S Filler Material (Below 50') <br /> .TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Q DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> available within 200 feet.) i <br /> .-Installation_will-serve:_,Residence.— -Commercia..l_„Other <br /> - ar <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Q Type/Mfg Capacity ' �N.o. Compartments <br /> PKG. TREATMENT PLT. ❑ ✓ C "FAetho <br /> d of Disposal <br /> Distance to nearest: Foundationyk <br /> Well,' <br /> i <br /> Property Line <br /> LEACHING LINE ❑ No. rat Length of lines Total length/size <br /> t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 3 <br /> SEEPAGE PITS ❑ Depth C Size Number <br /> SUMPS - ❑ Distance to'nearest: 'Well " Foundation Property Line <br /> DISPOSAL PONDS Q <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." <br /> The applicant st cal for all r uir i ctions. Complete drawing on rely rse side. <br /> Signed ` Title: cc Date: <br /> Date: <br /> j FOR DEP TMENT USE ONLY <br /> Application Accepted by / <br /> Date �- Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 0 <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 95201FEE + <br /> a <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 1324(REV.10!!'31 �r- m ^�c <br /> ' EH 1426 <br />