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APPLICATION FOR PERMIT <br /> fS <br /> w r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL ION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i 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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address <br /> Owper's Name <br /> ddress Phone <br /> ontractor - <br /> Address License No. Phone <br /> 'TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIO ❑ SYSTEM REP OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRI U E WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL REA CONSTRUCTION SPECIFICATIONS + <br /> ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation <br /> Dia. of Well Casing fAV� <br /> ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 7 e of Grout <br /> Grout--- <br /> n Public P Other Ll Delta th of Grout Seal YP — <br /> I I Irrigation __.-Approx. Depth 11 Eastern i Sur ce Seal Installed by - <br /> H.P. r State Work Done <br /> Repan Work Done El Type of Pump -- -- <br /> Well Destruction ❑ Well Diameter i Sealing Material (top 501 <br /> Depth Filter Material (below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR IADDITION l I DESTRUCTION (No septic system permitted if public sewer is <br /> iavailable within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> i 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 j Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ l Method of Disposak <br /> Distance to nearest: Well Foundation Property Line <br /> � I <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length,/size- <br /> FILTER BED fl Distance to nearest:I . Well Foundation Property Line <br /> a <br /> F � I <br /> SEEPAGE PITS VI Depth I Size Number <br /> I SUMPS ❑ Distance to nearest: Welt - Foundation. —., - - — Property Line <br /> DISPOSAL PONDS El <br /> I hereby certify that l 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, 1 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> - Title: <br /> L l Date: <br /> r <br /> �igned X <br /> FOB DEPA MENT USE ONLY ,fC <br /> Application Accepted by ZDate Area <br /> Pit or Grout Inspection by Date Final Inspection''bby <br /> Additional Comments: trtn. <br /> ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy %35-& 7 - a i t <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. HazeltonAve., P:O: x DP9 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED OKRECEIVED BYE'" ATE PERMIT-N . <br /> INFO Jp, [ <br /> +.EH 17.21(REV.1/H 5) 7 35, v� 3 �- 6,; <br /> 7 ✓ '"I ��� O[J O <br /> EH 14-26 - -� <br />