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APPLICATION FOR PERMIT <br />�r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ir-7,­,;� <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES VYEAR 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. <br /> Q' City Lot Size PM <br /> Job Address <br /> Owner's Name Address W v l Phone <br /> /w <br /> Contractor Address License No. Phone_ <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 WELt PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r ❑1ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> r Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> l { I Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 50'1 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l i DESTRUCTION lkl INo available septic <br /> system <br /> permitted if public sewer is <br /> Installation will serve: Residence— Commercial _ Other <br /> r, Number of living units: Number of bedrooms <br /> k Character of soil to a depth of 3 feet: Water table depth <br /> I! � SEPTIC TANK ❑ Type/Mfg s Capacity No. Compartments <br /> Method.of Disposal <br /> PKG. TREATMENT PLT. ❑ � .., <br /> i <br /> Distance to nearest: �.Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines { Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth `�' Size Number <br /> Su MPS Ll Distance to nearest: Well Foundation Property Line <br /> �p DISPOSAL PONDS ❑ " <br /> b 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 /> h z 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:pp <br /> d inspections. Complete drawing on reverse side.Title: Date: 2-- ZflSignd X <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> j Pit or Grout Inspection by Date Final Inspection b Date + r <br /> k <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 13 Trac 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOCa UNT DUE ZAMOUNT REMITTED- 6v CC-,.J/-1 GASH RECEIVED BY DATE PERMIT•NO. <br /> INFO 14157 �Sb <br /> t.EH13-24IREV..i/n51 [J+e <br /> EH 14-26 <br />