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4 APPLICATION FOR PERMIT <br /> ' SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> F Telephone (209) 466-6781 <br /> li PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> w <br /> N (Complete in Triplicate) <br /> u <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 e:0— A3 C SD, <br /> City Lot Size PM <br />, <br /> Owner's Name Address 0Phone <br /> I! <br /> Con tracI0-1 A Address �r.. r License No'1'`^'�Q <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 /> TS/SUMPSm4"T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Aomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'i Public FI Other ❑ Delta Depth of Grout Seal Type of Grout—_­ <br /> i I Irrigation —.k.Approx.=Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑,~Type of Pump 4rX4m= H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth T Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is 1 n <br /> ii i available within 200 feet./ V� <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 , <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ ;I <br /> 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 <br /> .i <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS t Cl_ Distance to nearest: Well r_ 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 la <br /> rules and regulations of the San Joaquin Local Health District. ws, and_ ; <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." p <br /> The applicant must calf r ail req�r 1 inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> II y <br /> i <br /> DEPARTMENT USEONLY � �J� r <br /> 11 , <br /> Application Accepted by Data <br /> Area <br /> Pit or Grout Inspection by �I Date Final Inspection by 1 Date <br /> Additional Comments: II <br /> ❑ Stk 466-6781 ❑ Lodi 1369-3621. ❑ 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 /> I. <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO. <br /> INFO CASH <br /> +.EH 1 .24 1REV.)/e 5] <br /> EH 1414-26 <br /> �7 3�a5 <br />