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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Womplete 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 weH/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> A <br /> Job Address !/AV <br /> City Lot Size <br /> P <br /> Owner's Name Address <br /> Phone <br /> tNEV . -650 <br /> � 3 5 <br /> Contra cEor Address cense N Pho <br /> TYPE OF WELL MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ DTHER-❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION - AGRICULTURE WELL, OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom, If Manteca Dia. of Well ExcavationDia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack r ❑ Tracy Type of Casing Specifications <br /> �.❑ Public ❑ Other – Cl Delta Depth of Grout Sea! Type of Grout _ <br /> I I Irrigation �F --App(ox. Depth i I Eastern Surface Seal Installed by i <br /> -Repair Wprk Done ❑ Type of`Pum <br /> ;• p H.P. State Work Done <br /> Well Destruction. ❑ Well Diameter Sealing Material Itop 50') <br /> Depth Filler Material (Be w 501) <br /> a <br /> STYPE OF SEPTIC WORK: 'NEW INSTA LATION 1:1 REPAIR•/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:' Residence— Commercial— Other <br /> Number of living units: / Number of bedroo s <br /> Character of sail to a depth of 3:feet: Water table depth 9� <br /> L�►S7� T <br /> SEPTIC TANK , ype/Mfg a e-POP. �/.PPy J Capacity No. Compartments <br /> ,PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r" Distance-to nearest: --, Well Foundation __ Property Line <br /> y' LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well—,1-167' Foundation Property Line _ <br /> SEEPAGE PITS If Depth y\ Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation , 41 <br /> Property Linef <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 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 shat!employ persons subject to workman's compensa- <br /> tion laws of'California." <br /> The applicant must call for all required inspect s. Co plate drawing on reverse side. <br /> Signed X Title: <br /> Date; <br /> FOR D PARTMENT USE ONLY <br /> Application Accepted by • Date/ 27 Area <br /> Pit or Grout Ins , <br /> pection.by Date Final Inspection by Date/ <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.D. Box 2009, Stk., CA 95201 \� <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> NFO CASH <br /> RECEIVED BY DATE PERMIT'NO. <br /> F �ff� <br /> +.EH13-24IREV. /n51 <br /> EH 14-26 <br /> I <br />