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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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 /> . i ot. ize r }� <br /> M+JobAddresa,(0 City �� <br /> Owner's Nam <br /> Address / �✓I Phone <br /> Contract$r" <br /> �5i i r Addres �-) vi <br /> � -- <br /> License N Phone <br /> TYPE OF WELL/PUMP: f i NEW WELT p .k '= WELL PEPLACEMENT 0 DESTRUCTION EJPUMP INSTALLATION ❑ – SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO <br /> PROP. LINE <br /> FOUNDATION AIGRICULTIJR'.WE OTHER WELL PITS/SUMPS <br /> ' `a INTENDED U E TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS ; <br /> r`'-D.Industrial f -O'Open Bottom anteca Dia. of � ell Excavation ° <br /> Dia. of Well Casing <br /> D Domestic/Private r '❑ Gravel t ❑ Tracy Type of Casin <br /> g Specifications <br /> /O Public ther ❑ Delta y <br /> f. ;� Depth of Grout Seal Type of Grout f <br /> ❑ Irrigation Jgpprox. Depth ,❑ Eastern Surface Seal Installed by <br />.. 1 Repair r Dond C3 Type 6f Pump H.P. <br /> State Work Done <br /> r <br /> Well Destruction . ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC'-WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No Septic system permitted'if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of Irvin units: Number of bedrooms <br /> Character of so to a epth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Ca acit i � <br /> p Y No. Compartmehts <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line I <br /> LEACHING DINE ❑ No. & Length of lines Total length/size <br /> :. <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS, ❑ Depth Size Number <br /> SUMPS .� L] Distance to nearest: Well Foundation `Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify th1t 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 Califorhia."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 appli )lust call for all re "red ins Complete drawing on reverse side. <br /> A <br /> Signed <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by. Date <br /> ' Area <br /> r , <br /> Pit or Grout inspection by + bate Final Inspection by s <br /> � . Dat�_.�� <br /> Additional Comments: <br /> ❑ Stk 466-6781 .❑ Lodi 369-3621 ❑ Manteca - 104 ❑ 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 REMITTED <br /> INFO K RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV. <br /> EH 1428 6H` <br />