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APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 1601 E. HAZETON AVE., STOCKTON, CA t <br /> Telephone (209) 466-6781 i! <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> x�. (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 !s <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 <br /> San <br /> �Joaquin <br /> Local Health District. <br /> PM <br /> Joky Address itl Lot Size <br /> Owner's Name ~ddress o. ` Phone <br /> Contractor's Name <br /> nse o. Phone <br /> TYPE OF WELLlPUMP: NEW WELL G WELL REPLACEMENT C DESTRUCTION G <br /> PUMP INSTALLATION 13 SYSTEM REPAIR 13 OTHER C <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 /> G Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing <br /> G Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casin Spec cations <br /> ElPublic 13Other G Deka Depth of Grout'Seal Type of Grout <br /> L Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by----- <br /> Repair <br /> y -Repair Work Done ❑ Type of Pumpt 4 H.P. State Work Done <br /> Well Destruction C Well Diameter I Sealing Material (top 501 <br /> Depth ' Filler Material(Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITION DESTRUCTION ❑ (Nailableo septic its tem permfeeited if public sewer is � <br /> ,i <br /> Installation will serve: Resid neemmarcial— 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 C Type/Mfg Capacity No. Compartments , <br /> PKG.TREATMENT PLT, C � —b--- Y <br /> Method o{Disposal <br /> Distance to nearest, ; Well Foundation Property Line <br /> D <br /> LEACHING LINE No. & Length of linesTotalrlength/size <br /> 96 C <br /> .: I <br /> FILTER BED ❑ Distance to nearest:' . Well s Foundation) Property Line D g <br /> r 1 <br /> SEEPAGE PITS C Depth 't2 Size Number C­ <br /> SEEPAGE <br /> SUMPS ❑ Distance to clearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl t <br /> state laws, and <br /> I hereby certify that I have prepared-this application and that the work will be done in accordance with San Joaquin county ordinances, <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the fol '.1 certify that in the performance of the work for which this per <br /> 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 /> 1 <br /> certifies the following <br /> :"I certify that in the performance of the work for which this perndt is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California," <br /> The applicant st r al rn ions. Complety7drawing on rse side. <br /> Signed -Title: <br /> 'Date: <br /> . _ t <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by <br /> Date L- - Final inspection by i 46 Date <br /> Additional Comments: <br /> 17 Stk 466-6781 ❑ Lodi 364-3621 G Manteca 823-7104 Cl Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 161D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERlNr1'TIO. l <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> I <br /> +EH 13-7x1(REV.10183 �% r t .: •� N/�b 3� <br /> EH 14-W O• O 6 <br />