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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601,E. HAZELTON 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 District for a permit to construct and/or install the work herein described.This application is <br /> It: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. J t t t . <br /> Job Address �� vim City, Lot Size PM <br /> Owner's N <br /> Address I Phone <br /> Contractor :Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ,.. <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation"" "�-- -�-Y--iia"of'Wel� asing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal € Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done + <br /> � l t z <br /> Well Destruction ❑ Well Diameter, Sealing Material {top 50'i 4g- <br /> Depth <br /> 6Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO e(No septic system permitted if public,sdWer is <br /> Aid available within 200 feet.) { l/ <br /> Installation will serve: Residence— Commercial Other � r <br /> Number of living units: Number of bedrooms I <br /> Character of soil to a depth of 3 feet: Water table depth <br /> Y+ <br /> SEPTIC TANK El Type/Mfg � CapacityNo. Compartments <br /> � p <br /> l PKG. TREATMENT PLT. ❑ Method of Disposal ; <br /> Distance to nearest: Well Foundation Property Line <br /> F t <br /> ti <br /> LEACHING LINE ❑ No. & Length of lines j Yotal length/size <br /> ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to neatest: Well ° Foundation Property Line <br /> 1 <br /> DISPOSAL PONDS ❑ <br /> 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. ` c <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." Coritractor'i-hiring or sub-contractirig 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." V <br /> ' The applic u all for all requ' in mplet rawin on r side. <br /> s Signed - Title: Dat <br /> FO EP TMIENT USE ONLY <br /> 'I <br /> Application.Accepted by Date Area d <br /> ' Pit or Grout Inspection by Date Final Inspection by Dat <br /> Additional Comments: <br /> ❑ Stk ' 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354i385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009r Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO IS7 <br /> + EH 13-24(REV.1/s 5) 13 � / "�-1 <br /> EH 14-26 <br />