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APPLICATION FOR.PlRMIT <br /> SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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. Tins 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 City Lot Size _ PM <br /> s <br /> Owner's Name Address JP Phone <br /> Contractor's Name �++� _ License No. > �� ��� Phone <br /> TYPE OF WELL/PUMP: NEW VZ1.F1 L' ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Q <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 /> JK Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth Q Eastern Surface Seal Installed by <br /> Repair Work7l)bne ',❑ Type of Pump H.P. _1?//111 State Work Done <br /> Well Destruction Cl Well Diameter Sealing Material (top 501 <br /> Depth ,� 5`' Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet) <br /> Installation will serve; Residence— Commercial—.,__Other <br /> Number of living units: Number of bedrooms I " <br /> Character of soil to a depth of 3 feet: I _Water table depth <br /> SEPTIC TANK ❑ Type/Mfg t '" �""'— I Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ � Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> j <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well I Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 r as to became subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I c at 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 must cal 11 r uire ins ons. Complete drawing on reverses <br /> Signed % � 4�.. Title: / <br /> Date: <br /> FOR DEPARTMENT US ONLY <br /> Application Accepted b Date ` Qf <br /> - 7 Area <br /> Pit or Grout Inspection Date Final Inspection by Data �✓ <br /> Additional Comments: <br /> ❑ Stk 468-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copi to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> j <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO." <br /> EH 1¢28 , All <br />