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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 /> PERMIT EXPIRES VYEAR 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. <br /> Job Address x <br /> City1"'.Lot Size PM <br /> J <br /> �—O <br /> wner's Name dress C" �— <br /> Phone <br /> Contractor Addressr <br /> Lice se Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 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 r Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications <br /> I I Public El Other F1 Delta Depth of Grout Seal <br /> Irrigation ,q Type of GrouE <br /> --Approx. Depth i I Eastern Surface Seal Installed by t <br /> Repair Work Done ❑ Type of Pump H.P. - t <br /> State Work Dane <br /> J Well Destruction ❑ Well Diameter Sealing Material (top 50')•, <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITIONI I DESTRUCTION INo septic system permitted if public sewer is I <br /> installation will serve: Residence_ Commercial_ Other vailable within 200 feet.I <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> e <br /> SEPTIC TANK , ❑ Type/Mfg Water table depth <br /> - <br /> Capacity---L. 1 No. Compartments <br /> PKG. TREATMENT PLT. ❑ ____j <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ OisfaM`i1-tenearest: Well -Foundation <br /> Property Line <br /> SEEPAGE PITS I'] Depth Size Number <br /> SUMPS. El Distance to nearest Well ' Foundation-„ Property Line <br /> DISPOSAL PONDS ° �❑ �" s � ' <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 k <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 applican ust call for all required inspec • ns. Complete drawing on reverse side. <br /> 41 Signed X_� 23 _ Title: D } <br /> ate: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Z� r <br /> -- Date <br /> Pit or Grout Inspection by <br /> _ Date Final Inspection by, � -- <br /> Additional Comments: <br /> `❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 96201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24+ EH 14.26 IREV.i i H sl J� <br />