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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> fComplete 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 <br /> made in compliance with San Joaquin application is <br /> 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 AddressCit <br /> r / YV4��' Lot Size .pM <br /> t <br /> Owner's Name i- ®t -c J Address U=0 tiC f' T"/ 1 <br /> Phone 96 <br /> I <br /> Contractor Address <br /> License No. Phone , <br /> TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. M <br /> PROP. LINE ! <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S <br /> ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> © Domestic/Private 11Gravel Pack# ElTracy Type of Casing Dia. of Well Casing <br /> Public <br /> M l Specifications <br /> ( ] Other Cl Delta Depth of Grout Seal <br /> Type of Grout <br /> I I Irrigation _ <br /> tf Depth ( I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump E H p <br /> State Work Done_ <br /> Well Destruction Cl Well Diameter Sealing Material (top 50') <br /> Depth I Filler Material(Below 50') ti' <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> Installation will serve: Residence—..'Commercial— Other available within 200 feet.) <br /> Number of living units:" Number of bedrooms <br /> Character of soil to a depth of 3 feet! <br /> SEPTIC TANK ' Water table depth <br /> ❑ Type/Mfg I Capacity— t <br /> P Y No. Compartments f <br /> PKG. TREATMENT PLT". ❑ Ca <br /> �6 Method of Disposal <br /> "Distance to nearest: Well. ? - Foundation Property.Line <br /> LEACHING LINE 4❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> I Property Line <br /> SEEPAGE PITS I I Depth I Size <br /> Number <br /> SUMPS fel Distance to nearest: - Well Foundation <br /> DISPOSAL PONDS ID " Property Line <br /> I hereby certify that I have prepared this applicationµand 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 fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not ­4 <br /> employ any person in such manner as to become subject io 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, f shall employ persons subject to workman's compenure <br /> tion laws of California." I <br /> sa- <br /> The applicant must call for all inactions. Complete drawing on reverse side. <br /> Signed X ^ r p r <br /> Date: , <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by t <br /> Date � '� rea V <br /> r1 Pit or Grout Inspection by Date Final Insp7fE�aa <br /> D to <br /> Additional Comments: 4 r waS Cer�{p/, <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Trac 635-6385 p� `f <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009tS k,CA952016 Ll1e j . <br /> SLP <br /> FEE <br /> CK <br /> INFO AMOUNT DUE ` AMOUNT REMITTED riECEIVED BY <br /> DATE tMPERMIT'NO, 3� <br /> +.EH 124(REV.i i H 51 <br /> EH 14-4-26 ! [� <br />