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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601'E..HAZE':—I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 NA <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 a i n <br /> is <br /> 62 <br /> R made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18for well/pump and the Rules and Regulations of the San cJoaquin <br /> Local Health District., <br /> dr <br /> Iit <br /> Job Address i Ci -" <br /> t Size ' PM-- <br /> Owner's Name Address <br /> Phone <br /> Contractor l!"' Address <br /> License IVo. Phone # <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ industrial <br /> ET Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ElDomestic/Private C3 Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> Type of Casing Specifications . <br /> E2 Public El Othp r ❑ Delta I. Depth of Grout SealSpecifications <br /> of Grout <br /> ❑ Irrigation --Approx. Depth El Eastern Surface Seal Installed by T <br /> Repair Work Done ❑ Type f Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material kop 50'} <br /> Depth:11 Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW!INSTALLATION ❑ REPAIR/ADDITI <br /> 11 ON LJ (No septic system permitted if public sewer is <br /> Installation will serve: Residence_` Commercial_ Other available within 200 feet.) <br /> t <br /> Number of living units: `Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK <br /> Type"/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> l Distance to nearest: Well Foundation Property Line <br /> i� <br /> LEACHING LiNE ❑ No. & Length of lines Total length/size <br /> FILTER BED + t❑ Distance to nearest: Well Foundation Property Line <br /> I 1 <br /> SEEPAGE PITS )<De " <br /> pth � Size _ Number <br /> i <br /> SUMPS ❑ Distance to nearest: Well .a Foundation Property Line <br /> DISPOSAL PONDS ❑ �� x <br /> hereby certify that I have prepared this application and that the work'will•be done in accordance with San Joaquin county ordinances, state lawsr 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 <br /> employ an - permit is issued, I shall not <br /> p y y person in such manner has to become subject to workman's compensation laws of California."Contractors 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 <br /> tion laws of California." p y persons subject to workman's compensa <br /> i�; <br /> The applicant mgst call for all required inspect'ons. Complete drawing on reverse side. ti _ <br /> Signed Title: ,c" pate: <br /> - g <br /> FOR DEPARTMENT USE ONLY ^ <br /> Application Accepted by iii ` •r x <br /> Date ' Area <br /> Pit or Grout Inspection b I bate Final Inspection by h, Date <br /> Additional Comments: +°r { <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S A 9520vv 1� N <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CK RECEIVED 9Y DATE PERMIT'NO. <br /> + EH1324[REV. <br /> EH.14-28 <br /> iM <br />