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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> r <br /> PERMIT EXPIRES 7 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." i , <br /> Job Address City Lot Size a/e&/` pjyl <br /> Owner's Name ,Address <br /> Phone <br /> Contractor <br /> ress License No Ph Re +l <br /> TYPE OF WELL/PUMP:7 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTI <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ THER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP FLD. PROP. LINE' <br /> FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO _ CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca� Dia. of Well Excavation Dia. of Well Casing <br /> ❑Domestic/Private C1 Gravel Pack ❑ Tr Type of Casing Specifications <br /> ❑ Public ❑ Other Delta Depth of Grout Seal <br /> Type of Grout <br /> ❑ Irrigation �4 epth ❑ Eastern Surface Seal Installed by ' <br /> Repair Work Done ❑ <br /> pe of Pump H.P. State Work,Done F= <br /> Well Destructi ❑ Well Diameter Sealing Material ftop 501 <br /> ' Depth Filler Material (Belo } <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION iE DESTRUCTION ❑ Mo 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_19==_ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK eType/Mfg i CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ ��— r <br /> » r <br /> ' 1 `" "" Method o 1 osal. <br /> —'Distance to nearest: Well f/ foundation--1 — Property Line— � <br /> 'LEACHING LINE ❑ No. & Length of lines Total length/size "r <br /> FILTER BEd ❑ Distance to nearest: Well "Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size NumbW i? <br /> ! SUMPS ❑ Distance 4-nearest: Well <br /> DISPOSAL PONDS El Foundation <br /> i Property Line F <br /> £ '.,... <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 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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." - i <br /> t The applicant must c I for all re uir in <br /> q pections. Comp to drawing on,r side. <br /> Signed Title: <br /> r Date: <br /> F D P RTMENT USE ONLY f 4- } <br /> Application Accepted by f pate I /!— <br /> t Area <br /> Pit or Grout Inspection by at <br /> Final Inspection by Date f , <br /> Additional Comments 0 <br />' ❑ Stk 466-6781 ❑ Lodi 369-3621. ❑ Manteca 823-7104 ❑ racy $35-6385 �(, r <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. zelton Ave., P.O. Box q 1 y�QQ� 46 <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CASH DATE PERMIT''NO. <br /> + EH 1324(REV.1/8 5) <br /> EH 14-28 Q. , I Y '•'�j <br />