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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 /> I' <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 i <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 0,:5 City Lot Size PM <br /> t /� ��1 <br /> Owner's Nam <br /> Address { � � phone <br /> Contractg ~ Address` lr G - �� � License No. Phan <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION P SYSTE=M REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i DISPOSAL FLD, PROP, LINE <br /> FOUNDATION,. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 6 CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> s <br /> Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> (Tl Public Cl Other 3�< F1 Delta Depth of Grout Seal Type of Grout ____—_ <br /> 3. <br /> I I Irrigation _.-Approx. Depth I 1 Eastern j Surface Seal Installed by <br /> i <br /> Repair Work Done ❑ Type of Pumper H.P. lState Work Done ( � <br /> "V <br /> Well Destruction 0 Well Diameter Sealing Material Itop 501 <br /> Depth Filler,Material (Below 501 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.l REPAIR/ADDITION'1'I_ DESTRUCTION I I (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 r ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of �i rYs / <br /> Distance to nearest: Well Foundation Property Line It" <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 4 <br /> FILTER BED ❑ Distance to nearest: Welk Foundation Property Line JUL V UJ <br /> SEEPAGE PITS i 1 Depth Size 4. Number SALTH <br /> SUMPS LI Distance to nearest: Well Foundation Property Line PERMIT/SFRVICF(" <br /> DISPOSAL PONDS ❑ <br /> 1 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 Di§trict. <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 applicant m nil for all wired inspections. Complete drawing.on reverse side. �. <br /> Signed X Title: . A&- Date: _2 <br /> 1 <br /> FO EPA ENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Cl Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 El 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 RECEIVED BY DATE PERMIT'NO. <br /> INFO rte— CASH <br /> + EH 13-24 IREV.I/n 51 <br /> EH 14-26 ✓"'� <br />