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APPLICATION FOR PERMIT I, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781, <br /> PERMIT EXPIRES.TYEAR 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 /> r /V Lot Size PM <br /> Job Address City <br /> Phone - - <br /> Water Supply:- Public system U�—Communify system ❑ Private ❑ Depth to Water Table -------- 3=f. <br /> �,onuacror�-�­— — - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ , DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ATIONS <br /> t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of xcavation <br /> Dia. of Well Casing \, <br /> Specifications <br /> r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Tp a of Grout <br /> f {1 Public t l Other Depth of Grout Seal i YP —" <br /> i ! I I irrigation .Appfox. 11 Eastern Surface Seal Installed by r <br /> k Repair Work Done ❑ T ump` H.P. State Work Done <br /> 5ealin Material'lto 50'1 j <br /> Well Destruction <br /> Well <br /> Diameter` g __ P 1" <br /> Depth Filler Material (Below-50'I`1. <br /> -"TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION LIDESTR CTIO available w thin 200 feet.) if public sewer is <br /> Installation will serve: Residence_ _i: Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soll to a depth of 3 feet: # <br /> f Capacity No. Compartments <br /> SEPTIC TANK; ❑ Type/Mfg . <br /> [71 Method of Disposal <br /> PKG. TREATMENT PLT. <br /> rJ 7 <br /> r Distance W nearest: Well Foundation Property Line <br /> "1 LEACHING LINE CI,rNo. & Length of lines Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> L •p <br /> I SEEPAGE PITS I 1 Depth <br /> Size Number r <br /> SUMPS Ll Distance to:nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> l 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 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 applicant ust call for all required inspections. Complete drawing on reverse side. <br /> f Signed X Title:" <br /> ' (� Date: <br /> x FQR DEPARTMENTUSE-ONLY �..C91-7 <br /> Date <br /> l Application Accepted by <br /> -�-L Area <br /> iy, E z Date <br /> Additional <br /> Pit or Grout Inspection by ^Date Final Inspection by <br /> �q <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 3694621 ❑ 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 95201 <br /> FET CK RECEIVED BY DATE PERMIT*NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> ♦ EH 13-24 IHEV.t/n 51 <br /> EH 14-26 <br />