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APPLICATION FOR PERMIT { <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601=E. HAZEL T ON AVE., STOCKTON, CA <br /> — -- a 4• Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j <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 City t Size @ PM <br /> Owner's Name Address Phone y� / <br /> Contractor's Name �� rise No. - Phone <br /> TYPE OF WELL/PUMP:=�2=NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ti OTHER D ` <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 i <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing—,F Specifications 1 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal___­-' Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H. State Work Done <br /> Repair Work Done ❑ Type of Pump r <br />` Well Destruction El Well Diameter Sealing Material (top 501 f <br /> Depth Filler Material (Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑1 REPAIR/ADDITION V DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available-within 200 feet.) <br /> Installation will serve: Residence Commercial_ 'Other ` <br /> x� t <br /> Number of living units: Number of bedrooms — , <br /> ' Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK © Type/Mfg Capacity ` -No. Compartments <br /> c ; Method of Disposal' <br /> PKG. TREATMENT PLT. ❑ , _ j r <br /> Distance to nearest: Well -Foundation Property Line <br /> t 4 .j'. Total length/size i <br /> LEACHING LINE ❑ No. & Length of lines <br />' FILTER BED ❑ Distance to nearest: }. WeFoundation 'Property Line <br /> SEEPAGE PITSDepth —Size Number <br /> '� ❑ Distance to nearest: Well A' 02 �,..� Foundation�� Property Line � `� `r t <br /> SUMPS -- <br /> DISPOSAL PONDS ❑ f - <br /> I hereby certify that I have prepared this application and that the-work;will-be done in accordanceµwith San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. .t ' <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 /> i <br /> The applicant must call II wired i ctions. Comple#e wing on re se side. _ ��—�_ . <br /> Signed <br /> Title: "Date: y <br /> FOR DE ENT USE ONLY / <br /> b \. Date rea <br /> Application Accepted y <br /> Pit or Grout Inspection by ✓ Date !! /I Final Inspection by Data f/ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Returnall copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED r CASH RECEIVED BY DATE PERMIT'NO. <br /> I X7 <br /> INFO <br /> + EH 13-24[REV.101631 <br /> I EH 14-26 - - - - i <br />