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APPLICATION FOR PERMIT <br /> s <br /> f k SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 1 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> .(Complete in Triplicate) <br /> I 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 /> 1 Local Health District. r <br /> Job Address CityAA�_IY7 Lot Size PM <br /> 1 Owner's Name Ai El Address Phone f� <br /> Contra ctor0�L� ddress ` /%- / 6 License fVo��.7..�_Phone T <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT d 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 PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom E) Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'] Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout--- <br /> I <br /> rout YI 1 Irrigation _Approx..Depth 1 1 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 <br /> Depth Filler Material`(Below 50') -- <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION l 1 DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, L1 ' Method of Disposal <br /> r <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well _Foundation Property Line <br /> I ' <br /> SEEPAGE PITS l I Depth Size Number <br /> C SUMPS El Distance to nearest: Well Foundation Property Line <br /> t 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 /> 1 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 applican st a I for all required spections. Co plate drawing on reverse side. <br /> Signed X Title: Date: <br /> EP T NT USE ONLY Q <br /> Application Accepted by Date _ Area <br /> Pit or Grout Inspection by bate Final Inspection by <br /> Date <br /> r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 _ ❑ Manteca 823-7104 ❑,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. AMOUNT DUE 'AMOUNT REMITTED SCK-H RRECEIVED BY' DATE PERMIT'NO. <br /> INFO <br /> +.EH13-24(REV.i/x5) `p� <br /> EH 14-26 V <br />