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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1801 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209? 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 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 /> t <br /> Job Address -! City Lot Sizeov 4D-- PM <br /> Owner's Name Address Phone <br /> P� <br /> Contractor w Address /-'" l=icense-NPhone =, 2 Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack r" ❑ Tracy Type of Casing, Specifications <br /> f7 Public ❑ Other E-] Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —.Approx. Depth I I Eastern Surface Seal 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 f 1 REPAIR/ADDITION I ! STRUCTIO"I <br /> o septic system permitted if public sewer is /'1! <br /> ��� ailabl wit 200 feet.) li <br /> Installation will serve: Residence____ Commercial_ Other � <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth v 1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ T _ —Met, of Disposal <br /> Distance to nearest: Well Foundation 9 Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS Ll 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 must call for II required inspections. Complete drawing on reverse side. �r q <br /> Signed X Title: Date: <br /> w FOR DEPARTMENT USE ONLY <br /> Application Accepted b Date Area <br /> Pit or Grout Inspec ' y final Inspection by ` Date bvC <br /> Additional Comments: I <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 - ❑ Manteca 823-7904 ❑ Tracy 836-631M <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 AMOUNT REMITTED CK RECEIVED BY DATE PERMWN0. y <br /> { INFO CASH <br /> r EH 13-24{REV.i/H 51 �r 3 <br /> EH 14-28 <br />