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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT ��41 <br /> { 1601 E. HAZETON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r <br /> ti r (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 Add <br /> Job A <br /> City Lot Size PM <br /> _ .'"3 y <br /> Address y4 Phone ^� <br /> Ownews' 1 <br /> 07 <br /> Contr <br /> ess r (cense No. hone' <br /> TYPEMP: NEW WELL ❑ WELL REPLACEMENT ❑ 1 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE s <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ElTracy Type of Casing <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> f' <br /> i ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done r <br /> IWell Destruction ❑ Well Diameter Sealing Material ttop 50'I ^h Depth Filler Material (Below I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Wr DESTRUCTION ❑ (No septic system <br /> in rented if public sewer is <br /> avaInstallation will serve: Residence commercial 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 ❑ Type/Mfg Capacity No, Compartments I !1 <br /> Method of Disposal 1 <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines Total lengthlsize <br /> FILTER BED 1:1Distance to nearest: Well Foundation Property Line <br /> 5 <br /> SEEPAGE PITS LlDepth Ix ize """ "Numtier 'r 4 <br /> SUMP ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ # a + <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�lavvs 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must oWi for ail req uired'inspections. Complete drawing on rey@rse side. <br /> Date: <br /> Signed Title: <br /> FOR DEPARTMENT USE ONLY 1 �- <br /> DateQs� Area G� <br /> Application Accepted by `,Irn <br /> p�Inspection by Date Final Inspection by Date 7 a(a <br /> Additional Comments: " <br /> El Stk 466-6761 E3 Lodi 369-3621 L] Manteca 823-7104 ❑ Tracy 835 6385 �M <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I FEECK RECEIVED BY DATE PERMI <br /> INFOT`NO. <br /> i' <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> t EH 13-241REV,x/65) � i '� `� <br /> !!!� a Oa '. � <br /> EH 1428 <br /> 1 <br />