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�Sf <br /> APPLICATION FOR PERMIT F---` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � • � W� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 O <br /> PERMIT EXPIRES TYEAR 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 /> Job Address ` St. City Lot Size PM <br /> Owner's Name Address Phone <br /> Contract AddresV— License No_ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - <br /> PUMP INSTALLATION ❑ SYSTEM R IR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU,pel4N SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of ell E cavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty p of Ca Specifications <br /> I-I Public F1 Other ❑ Delta D pth of Gr ut Seal Type of Grout <br /> I Irrigation —..Approx. Depth I I Eastern Surface S I 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 I I REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is <br /> f /available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other ✓xc�/j <br /> Number of living units: Number of bedrooms 7 <br /> ��itcl�2 ' <br /> Character of soil to a depth of 3 feet: I..tCompartments <br /> er table depth i r <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT. ❑ 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 Q <br /> SEEPAGE PITS I ] Depth Size Number <br /> SUMPS Cl 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 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 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant yqust call for al quired i pections. Complete drawing on reverse side, <br /> Signed X r Title: V — Date: <br /> OR DEPARTMENT USE ONLY Q <br /> Application Accepted by Date `— ` Area J <br /> Pit or Grout Inspection 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.O. Box 2009, Stk., CA 95201 <br /> CK <br /> )NFO AMOUNT RUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> FEE EH 1 <br /> 3-11 IR EV.I/R5) �'ly� /I /'� 7� <br /> EH 14-26 '(2 <br /> �O <br />