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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> �. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or iq tall 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/purripland the RuIR&arid Regulations <br /> �ofit'hheGSan <br /> Joaquin <br /> Local Health District. 7 G a� t / Ig7a <br /> U t City Lot Size PM <br /> Job Address <br /> Address Phone <br /> Owner's Name � — ' <br /> Contractor's Name <br /> License No. Phone <br /> _ <br /> DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT El OTHER <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK �!/- SEWER LINES" x_ DISPOSAL FLD. r./f.PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation �` 5pecifications - <br /> momestic/Private ravel Pack U�cy Type of Casing_ <br /> ❑ Public ❑ Other Ll Delta Depth of Grout Sea! <br /> Type of Grout <br /> ❑ Irrigation —�pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H.P. <br /> State Work Done <br /> Well Destruction ❑ Wel! Diameter Sealing Material (top 50'! <br /> I Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ availableNo septic <br /> wthin 200 feet.) <br /> tem permitted <br /> if public sewer is <br /> Commercial_ Other <br /> Installation will serve: Residence— Com �. <br />+ Number of living units: Number of bedrooms Water table depth <br /> f Character of soil to a depth of 3 feet: No, Compartments C <br /> SEPTIC TANK ❑ Type/Mfg' Capacity <br /> PKG. TREATMENT PLT. ❑ t 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 Property Line — <br /> SEEPAGE PITS ❑ Depth. I Size - - -Number- <br /> } Property Line <br /> SUMPS - Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ k <br /> I 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 /> l 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 Cal"ornia." <br /> The appfcant ust call for all requ" inspections. C mplete drawing on A,..evped 1 �� <br /> Signed <br /> Title: Date: <br /> FOR DE TM <br /> US ONLY <br /> � Date Area 0/7Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 <br /> Cr <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r T D <br /> i GO <br /> FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT"NO. <br /> INFO 1' <br /> + EH13-24{REV.101831 <br /> FH 14_26 �` - <br />