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APPLICATION FOR PERMIT <br /> a 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 /> City Lot Size PM <br /> Job Address <br /> Phone <br /> Owner's Name ss <br /> i7 <br /> '� License No, r Phone <br /> ❑ DESTRU <br /> Cantractol( v- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CTION LJ <br /> PUMP INSTALLATION L] SYSTEM REPAIR L] OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> _ :=--FOL�NDATION �=-� 4AGRICULTURE W.ELL� = aTH.ER W.ELL. —I'ITS15l7MPS — = <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation <br /> Type of Casing Specifications <br /> I omestic/Private ❑ Gravel Pack racy yp g Type of Grout <br /> r.I Public F1 Other ❑ Delta Depth of Grout Seal <br /> I 1 IrrigationApprox. Depth I I Eastern Surface Seal Installed by <br /> �e of Pump H.P. —� State Work Don <br /> Repair Work Done c;,_ Typ <br /> k Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> I Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION IJ DESTRUCTION I I avlo septicailable system <br /> m rented if public sewer is <br /> Installation will serve: Residence— Commercial — Other <br /> I Number of living units: Number of bedroomsWater table depth <br /> �. <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments <br /> 11Method,of Disposal <br /> PKG. TREATMENT PLT. <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 l I Depth Size Number <br /> SUMPS L! 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 Hearth District. <br /> following: "I.certify that in the performance of the work for which this permit is issued, <br /> Home owner or licensed agent's signature certifies the I shall not <br /> ompensation laws of California." Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's c <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 required ins actions. Complete drawing on reverse side. <br /> i Title: Date: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY a I <br /> _�* <br /> Application Accepted by <br /> Date / Area <br /> Pit or Grout Inspection by 15D __ateFinal Inspection by <br /> G– Date 6 �� <br /> r• <br /> Additional Comments: <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, Silk., CA 95201 <br /> FEE K RECEIVED BY DATE PERWVNO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> +. <br /> EH 13-21 IFtEv.i K!5) . C 0 <br /> EN 14-26 <br />