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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE'TON AVE. STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (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 <br /> City�Qe&m4ot Size PM <br /> Owner's Name Address <br /> P ne <br /> Contractor's Name /d�fj',! �i�T'�� •SSS• <br /> tLicense No. _ <br /> t TYPE OF WELL/PUMP: Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION S wV E4k SYSTEM REPAIRkj OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> EWER LINES DISPOSAL FLD. PROP. LINE J <br /> �FO,UNDQT.ION _AGRICULT•URE VlIELL rpT.HER_WELI�'� �- <br /> INTENDED USE PITS/SUMPS _. <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> )ODomestic/Private Gravel Paokl 1 1% 6Dia. of Well Casing <br /> ❑ Tracy Type of Casing_ � L' <br /> ❑ Public Ty <br /> Specifications .r4fie /4 <br /> ❑ Delta Depth of Grout Seal �t- <br /> ❑ Irrigation '�X 4T,,,' /0pprox. Depth ID Eastern Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done Y / <br /> '`� w Type of Pump1: .. <br /> Wall Destruction --� —-H.P-... <.� State Work-Done <br /> Well Diameter <br /> ❑ <br /> Sealing Material (top 50')T <br /> Depth `'_ Filler Material (Below 501) 1100, <br /> TYPE OF SEPTIC WORK: NEWll-INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION L1 fNo septic system permitted if public sewer is <br /> i S G`a <br /> Installation will serve Residence available within 200 feet.) <br /> ,,f Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: b '~"� <br /> SEPTIC TANK Water table depth <br /> PKG. TREATMENT PLT ❑ TYpe/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> Distance to nearest Well Foundation <br /> p Property Line <br /> � 3b <br /> LEACHING LINE Ll--No. & Length of linesTotalBED Total length/size a.R� <br /> 1 ❑ Distance to nearest: Well Foundation A <br /> .,,,,,,,.;.+ Property Line <br /> SEEPAGE PITS ❑ Depth fSUMPD <br /> p Size Number <br /> 'DISPOSAL <br /> �❑ Distance to nearest: Well <br /> DISPOSAL PONDS ❑ � Foundation Property Line S <br /> 1 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 Ry <br /> rules and regulations of the San Joaquin Local Health District. _ <br /> Home owner or licensed agent's signature certifies the following: "!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 1 <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 a required inspections. Complete drawing on reverse side, <br /> Signed X '% - <br /> _itle: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by t <br /> Date y' Area l <br /> Pit or Grout Inspection by /�( Date -�-� p Y l <br /> Final Ins action b 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 /> FEE AMOUNT DUE �. � AMOUN MITTED CK# <br /> INFO CASH RECEIVED BY DATE PERMIT'N0. <br /> + EH 13-24 1REV.19/631 y <br /> EH 14-26 <br />