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APPLICATION FOR PERMIT <br /> SAN JOAQUIN _LOCAL HEALTH-OiSTRICT �. <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA ` <br /> Telephone 12091 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 /> ~ t / r <br /> Job Address City Lot Size` t PM <br /> C�" Address 7307 ./. Cl T I� f�i 11� y,7 J <br /> Owner's Name _ Phone 'T <br /> Contractor Address <br /> License No. - Phone <br /> Y TYPE OF WELL/PUMP: _ NEWWELL.❑ WELL REPLACEMENT ❑ 4 DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El 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 CONSTRUCTIISPECIFICATtONS <br /> ❑ Industria! ❑ Open B m ❑ Manteca Dia. o all Excavation Dia. of Well Casing <br /> ❑ Domestic/Private LJ Gravel Pack ❑ Tra <br /> cy of Casing Specifications <br /> + ❑ Public ❑ Other ❑ De to Depth of Grout Seal ° Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Easte Surface Seal Installed by � { <br /> Repair Work Done ❑ Type of Pump t: H.P. _ t State Work Done I <br /> Well Destruction ❑ Well Diameter. Sealing Material [top 501 r <br /> Depth Filler-Material 413elow 501 <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 'P r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity— <br /> INo. Compartments <br /> PKG. TREATMENT PLT. 71i Method of Disposal <br /> Distance to nearest:—Well�—�—— --�-Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of-lines Total length/size d <br /> FILTER BED " f <br /> ❑ Distance to nearest:' Well Foundation Property Line a <br /> SEEPAGE PITS 0 Depth N Size Number <br /> S El <br /> --T <br /> SUMPDistarice to nearest. Well Foundation <br /> 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 LocalHealth 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 Califorrna." 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, 13shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must`II for all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: a <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b Date SSI Are, <br /> Pit or Grout Inspectto Date Final Inspection by pat I <br /> Additional Comments: ;, <br /> ❑ Stk 466-6781 ❑ Lodi-369-36211 ❑ 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 CK 4T RECEIVED BY DATE PERMIT'NO. <br /> INFO i <br /> + Em 3-24 EH 14-28IflEV.i/85) (� <br /> t 1 I � <br />