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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 4_6 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 <br /> P1/] r <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � �1 <br /> � L <br /> (Complete in Triplicate) <br /> s <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 A/ City Lot Size PM <br /> Owner's Nam i f Address Phone — p <br /> 9 i <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Cl.-Manteca of Well Excavation —Dia. of Well Casing <br /> ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout <br /> i <br /> I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by n r <br /> Repair Work Done ❑ Type of Pump W.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material ftop 501 f i 1Vl <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION 1.1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <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 tab/ depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of! <br /> pisposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> F FILTER BED ❑ Distance to nearest: Well Foundation Property Line <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 all required inspections. Complete drawing on reverse side. <br /> r s <br /> �/ Signed Title: ®h / Date: <br /> /` j FOR DEPARTMENT USE ONLY <br /> Application Accepted,b ._ Date �G --?V Area <br /> i <br /> Pit or Grout lnspecti y Date Final Inspection by Data <br /> Additional Comment V <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 AMOUNT REMITTEDCK R RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> a EH 13-24(REV.t/N s7 �— <br /> EH 14-26 V d %%% <br />