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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON,AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />I eAMIT 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. ,.. •n. # <br />1 <br />j r 5 <br />Job Address City Lot Size PM <br />Owner's Name AddressPhone <br />/ <br />AMOUNT DUE <br />AMOUNT REMITTED <br />Contractor's Name <br />RECEIVED BY <br />License No. Phone <br />TYPE OF WELL/PUMP: NEWWELL❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION46SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK 1 _SEWER LINES DISPOSAL FLD.___ PROP. LINE <br />4., <br />FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA., CONSTRUCTION SPECIFICATIONS i <br />❑ Industrial ❑Open Bottom ❑ Manteca `',Dia.�of Well Excavation Dia. of Well Casing <br />of <br />❑ Domestic/Private sGravel. Pack ❑ Tracy Type of Casing Specifications <br />❑ Public ❑ Other *%,LDelta Dept* of Grout Seal Type Iof Grout <br />❑ Irrigation J—Approx. Depth ❑`Eastern Surface Seal Installed by i <br />Repair Work Done ❑ Type of Pump I H. P. State Work Done <br />Well Destruction C1We11 Diameter Sealmg,Material {top 501 i <br />Depth Filler Material iBelow�S <br />') I <br />TYPE OF SEPTIC WORK: NEW INSTALLATION C1 REPAIR/ADDITION " 11(No septic system permitted if public sewer is <br />DES_RUCTION <br />available within 200 feet.) <br />Installation will serve: Residence i Commercial _ Other <br />a' <br />Number of living units: Number of bedrooms <br />Character of soil to a depth�of 3 feet: t Water table depth-, <br />SEPTIC TANK ❑ Type/Mfg ) Capacity No. Compartments <br />PKC. TREATMENT PET. ❑ r Method of Di Alo <br />'Distance nearest: //�/ Xl 1i <br />Well A�Fbundation Property Line <br />to — <br />.t I <br />LEACHING LINE +�f❑ 'No. & Length'of linesTotal length/size I <br />FILTER BED Q Distance to nearest: Well Foundation Property Line t <br />SEEPAGE PITS �. ❑Depth Size l Number <br />SUMPS . = 0 Distance to nearest: Well Foundation Property Line <br />DiSPOSAAONDSN ❑ �I. <br />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 t all for <br />all yr Inspections. Complete drawing on 7se side. <br />Signed ! ��� -'Title: &Eef2l ®— Date: <br />F R DEPARTMENT USE ONLY <br />Application Accepted by Date -3 v raj Area <br />Pit or Grout Inspection by Y r Date Final Inspection by Date <br />Iv -3! <br />Additional Comments: <br />❑ Stk 466-6781 ❑ Lodi 369-3621 = ❑ Manteca 823-7104 ❑ Tracy 83540% <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br />i� <br />t EH 13-24 1REV. 10!831, <br />EH 1428 <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CK <br />CASH <br />RECEIVED BY <br />DATE <br />PERMIT"NO. <br />4 <br />// <br />