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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 /> PERMIT EXPIRES 1YEAR 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 Counry Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> l j <br /> Job Address /J -/� �La4� City_�j?71_A F Lot Size PM <br /> Owner's Name Address Phone <br /> Contractor .Q�44, Gz - 2 - Address F, 0, /�� License No�A� Phone lS <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 r <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑-Domestic/Private ❑ Gravel Pack .❑ Tracy Type of Casing Specifications <br /> M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Ifticgation --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 JQ <br /> Depth filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is lZi <br /> ' it f available within 200 feet.) <br /> Installation will serve: Residence le:5-'Commerciat— Other '` <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> f­SEPTIC-,TANK-- Type/Mfg"'� ^" Capacity No. Compartments ; <br /> PKG. TREATMENT PLT. ❑ r� ,� Method of Disposes <br /> t <br /> Distance to nearest: Well Foundation /,9d Property Line �_r1 <br /> LEACHING LINE ❑ No. & Length of tines ! Total length/size mm <br /> FILTER BED ❑ Distance to nearest:--- Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size f _ Number <br /> SUMPS t„= - L,4, Distance•to nearest Well Foundation Property Line <br /> DISPOSAL PONDS ` ❑} ' <br /> I hereby certify that I have prepared this application and drat the.w'ork will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the:San`Joaquin Local Health Distr6 i <br /> Home owner or licensed agent's signature certifies the following_""1 certify that-'inthe•performaince of the work for which this permit is issued, I shall not - <br /> employ any person in such manner as to become subiect 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 far all qulred inspections. Complete drawing on reverse side.f <br /> Signed X � Title: Date: <br /> Date: <br /> F EPARTMENT USE ONLY <br /> Application Accepted by Date Area ;1 <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 k- - ---AMOUNT-'REMITTED)-• CK+` =-REGEIVED•BY - ----�- DATE- +•�*- *PERMfT_NOr <br /> INFO CASH" <br /> + EH 13-24(REV. <br /> EH 1426 ^1ti <br />