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APPLICATION FOR PERMIT <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.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 .a„ <br /> � = City Lot Size PM <br /> Job Address _ <br /> ddress <br /> Phone <br /> Owner's Name <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> f DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL FLO. PROP. LINE <br /> k FO TION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> l INTENDED USE TYPE OF WELL PROBL RUCTION SPECIFICATIONS <br /> f <br /> F! Industrial ❑ Open Bottom ❑ Manteca Pia. of W Dia. of Well Casing <br /> l ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications <br /> ❑�Public ❑ Other ❑ Depth of Grout Seal _ Type out <br /> Ll Irrigation ---Approx. De ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of p H.P. State Work Done 01 <br /> Well Destruction ❑ Diameter Sealing Material (top 50') Ul <br /> Depth Filler Material !Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUC71ON (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 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT.\ <br /> � <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines` <br /> S <br /> FILTER BED ❑ Distance to nearest: 4 Well Foundation Property Line <br /> i <br /> E <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 /> i 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." Contractors 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 /> i The applicant must call for all required inspections. Complete drawing onr rse side�.�, Q/J <br /> Signed _TG^(/�r „-'v `� Date: <br /> FOR DEPARTMENT USE ONLY Q' <br /> ;:Application Accepted Date 1 C>— ` Area <br /> Pit or Grout Inspectioby Date Final lnspel6on by <br /> Date Y—� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IQKFEE AMOUNT DUE AMOUNT REMITTED CXV RECEIVED BY DATE , PERMIT N0. <br /> INFO '73 <br /> + EH 13-24(REV.1/65) IS� -7 S �O r 3 <br /> EH 14-28 <br />