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APPLICATION FOR PERMIT <br /> y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—1 ON 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 SanJoaquin 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. R �, <br /> Job Address 22 S City Lot Size PM <br /> Owner's Name Address 12 ` 6 Phone 5 <br /> Contractor's Name !625�4_) - License No. Phone S� <br /> TYPE OF WELL/PUMP: VNEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKTZQO" SEWER LINES DISPOSAL FLO.If PROP. LINE f <br /> FOUNDATION - AGRICULTURE•WEL-L�=-- BOTHER-WEL1:�""­ PITS'/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ff <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> )KDomestic/Private AGravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public E] Other LJ Delta Depth of Grout Seal Type of CKout ! <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump l H.P. State Work Done <br /> Well Destruction ❑ Well Diameter' I Sealing Material (top 501 <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) t <br /> Installation will serve: Residence (Commercial_ Other <br /> Number of living units: Number of bedrooms i <br /> Character of soil to a depth of 3 feet: I _—Water table depth <br /> SEPTIC TANK ❑ Type/Mfg .1 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line 5 <br /> SEEPAGE PITS ❑ Depth I Size Number <br /> SUMPS El Distance to nearest: Well Foundation_ Property Line <br /> ^� •DISPOSAL-PONDS — ❑ ,. <br /> i <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 applic ust call fob all quire i spections. Co plate drawing on reverse#e. , <br /> Signed X Title: Date: <br /> FOR DEP R MENT USE ONLY <br /> Application Accepted by Date �f Area O <br /> Pit or Grout Inspection by Date Final Inspection by Dat <br /> Additional Comments: P� h � � <br /> ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 823-9104 ❑ 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 /> FEEAMOUNT DUE AMOUNT M NT REMITTED C RECEIVED BY DATE PERMIT'NO.' <br /> µ <br /> INFO ' <br /> + EH 13.241REV.10133) 'fir}i l3 <br /> EH 1426 <br />