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°- APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �y <br /> 1601 E. HAZE LTON AVE.,.STOCKTON, CA Spm 2� <br /> -Telephone (209) 466-6781 I <br /> %.e,. ni t- ' <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. I y _ ,, , . r ; - f,. . <br /> Ot <br /> Job Address b a �' City"r Lot Size P <br /> �- VAI s <br /> WLiLS' � Al / t'none <br /> Owner's Name <br /> Contractor� Address License No. Phone <br /> TYPE OF WELL/PUMP: !? NEW 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 r� <br /> INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS —N4 <br /> [I Industrial E y Open Bottom L1Manteca Dia..of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i C1Public 171Other 71Delta Depth of Grout Seal Type of Grout <br /> ElIrrigation _.'_4pprox. Depth ElEastern Surface Seal Installed by <br /> Repair Work!Done LlType of Pump H.P. State Work Done <br /> r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material [Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ElDESTRUCTION No septic system permitted if public sewer is <br /> F available within 200 feet.) <br /> Installationwill serve: Residence— Commercial_ Other <br /> r <br /> Number of living units: Number of bedrooms <br /> r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> I SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal <br /> f k 1i-Distance to nearest: Well a Foundation Property Line <br /> '��:Y� <br /> LEACHING LINE t\r O =No. a Lengthtof lines,° _ Total length/size <br /> FILTER BE©tom• y❑ a Distance'to nearest: Well Foundation Property Line <br /> R ' ti t <br /> SEEPAGE PITS ❑ ` Depth E, Size` Number <br /> 1i SUMPS ❑ Distance to nearest: Well{ Foundation Property Line ; <br /> t DISPOSAL PONDS ❑ 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordarice with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District.t <br /> i. 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 law's 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 must call for all requir inspections. Complete drawing on reverse side. <br /> Signed X tt, Title: Da7te: 1,;--/ <br /> jI FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date ` — O✓ Area <br /> Pit or.Grout Inspection by Date Final Inspection by Date ,>—L10 <br /> t e� Cd C-1 <br /> rtronaI Comments: <br /> Stk 466 6781 ❑ Lodi 369-3101 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> Wppticant Return all copiesto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIYNO. <br /> -+ EH 13-241REV,t/H5] INFO <br /> EH 1426 <br /> l; - <br />