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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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. l <br /> Job Address o CityLot Size Ftl�ul <br /> Owner's Name Address Phone <br /> G <br /> eI <br /> Contractor �� Addresses License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ q , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �j]"` <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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other - ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ff REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence ZCommerGial_ Other <br /> Number of living units: Number of ed oms 44 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity—LNo. Compartments <br /> PKG. TREATMENT PLT. ❑ jt7 I Method of Disposal <br /> p <br /> Distance to nearest: Well 1 Foundation Property LineD <br /> _- <br /> LEACHING LINENo. & Length of lines Tptal length/size <br /> FILTER BED ❑ Distance to nearest: WellwZy Foundation Flo Property Line <br /> �r <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line 0 <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 i ed, 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-cor tS racting 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 applican o q iu r p inspections. C pfete drawing on verse side. <br /> Signed X n i �/ Title: Date: <br /> FORD ARTMENT USE ONLY <br /> Application Accepted by // Date ��Ag Area <br /> Jl <br /> Pit or Grout Inspection by � DateaI Inspection by Date! <br /> Additional Comments: / <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823 7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,FEE <br /> 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY / DATE PERMIT NO. <br /> + EH13-24(REV.t/b5) <br /> EH 14-28 <br />