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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT C <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {2091 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby maade 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. I� <br /> Job Address City of Size PM <br /> Owner's Name Address _ Phone <br /> Contractor /. !V14 Address License Phor cJ'Cl � <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 WPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteba ell'Excavation Dia.of Weil Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing Specifications <br /> Gl Public F1 Other Delta Depth of Grout Sea{ Type of Grout <br /> I I Irrigation �.Ap epth 11 Eastern Surface Seal Installed by <br /> F <br /> Repair Work Done ❑ e of Pump H.P. State Work Done <br /> Well Destruc ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION l I DESTRUCTIO No septic system permitted if public sewer is 1 <br /> l vailable within 200 feet.l <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: f- Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT- ❑ Method of Disposal <br /> Distance to nearest; Well Foundation —-- - ----Property-Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number; <br /> SUMPS ❑ . 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 shalt not <br /> employ any person in such manner as to become subject to workman's'compensation taws 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 pefmit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appli nt must call for all requir in cti ns. Complete drawing on reverse ide. � <br /> Sign Title: _.� �,�"�� Date: <br /> Application Accepted by l !/LGA __ 1 Date Area 13 <br /> Pit or Grout Inspection by Date Final Inspection by l Date MALLI <br /> Additional Comments: U <br /> Stk 466-6781 L] Lod ❑ Manteca a23-7104 ❑ 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.11 H 5) / / � <br /> EH 14-28 / <br />