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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ,� V — City Lot Size PM <br /> Zi <br /> Owner's Name ress / /y} Phone <br /> 2-17 <br /> Contractor's Name cense No. ( ` Phone <br /> TYPEOFWELL/PUA NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ C <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> r <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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <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 /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Belo ') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATI N ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> r <br /> Number of living units: Number of bed oms� _, /po <br /> Character of soil to a de h of 3 feet: Com4,- Water table depth <br /> SEPTIC TANK ❑ Type/Mfg —ZWCapacity No. Compartments <br /> PKG. TREATMENT PLT.❑ f t Method of Disposal <br /> Distance to nearest: Well Im Foundation /Q Property Line <br /> LEACHING LINE It No. & Length of linestTotal length/size <br /> FILTER BED ❑ Distance to nearest: Well.114)e Foundation 4 Property Line�- <br /> SEEPAGE PITS X Depth — Size 1 / Number <br /> SUMPS ❑ Distance to nearest: Well-.j-T n Foundation /OD Property Line s <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 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."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 ny��te�[�-f(op'all�reeqq�uire 'n ctions. Comp <br /> /jJJR��ctte/c/drawing on rev a side. ^7, <br /> Signed X c� / r/ / Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �7 Date Area - <br /> Pit or Grout Inspection byDID <br /> Date Final Inspection by Date <br /> r^ , <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lod-- Manteca 823-7104 ❑Tracy 8356385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERmri NO. <br /> + �EH IX24 <br /> EH 1436(REV.f010180) = 85f <br />