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APPLICATION FOR PERMIT <br /> r,$0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone Q09) 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 Districi for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance N f sewage or 18 or well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> q P1 <br /> Job Address ity Lot SizeXAU2PM�( <br /> 9 <br /> Owner's Name dress Phone <br /> V <br /> Contractor AddressUos 5 License No. Phone 71/_ <br /> TYPE OF WELL/PUMP: NEW WELL❑ WELL REPLACEMENT ❑ DESTRUCTION-O—'— <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SE R LINE 4 DISPOSAL FLO. <br /> PROP. LINE <br /> I FOUNDATION AGRI ULT RE WELL" OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public f7 Other Cl Delt Depth of Grout Seat Type of Grout _ <br /> I I Irrigation ­ ,Approx. Depth I I E tern Surface Seal Installed by <br /> Repair Work Done ❑ Type o1 Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Seali Material (top 5011 <br /> Depth Filler aterial (Below 50') 0 <br /> TYPE OF SEPTIC WORK: NEW INSTALION I#T REPAIR/ADDITION I I DESTRUCTION I ! (No septic system permitted if public sewer is p j <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. ❑ Method of Disp sa <br /> Distance to nearest: Well Ni0Nndation a] Property Line <br /> LEACHING LINE ❑ No- & Length of lines otal length/size 7 <br /> FILTER BED ❑ Distance to nearest:f Well A I&C Foundation Property Line <br /> SEEPAGE PITS I l Depth 2Inerest <br /> Size Y Humber <br /> SUMPS Li Distance tWell r dyle Foundation.�7_7/tT Property Line S <br /> DISPOSAL PONDS ❑ PP�� <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 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 call for alk re ed inspe ions. Complete drawing on reverse side. <br /> Z5 <br /> Signed X Title: Date: <br /> w <br /> FOR DEPARTMENT USE ONLY [ 1 <br /> Application Accepted by Date —�+ �v { <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: ✓ Pv�c �r]t Q I the 5 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 V0 M teca 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. <br /> + EH 13-24(REV.ti851 17� (]� <br /> EH 14-26 <br />