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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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.] 1 <br /> Job Addre; 5 ` 3:�; / <br /> City Lot Size PM <br /> Owner's Na Addren=4 <br /> Ne Phone <br /> S <br /> Contracto - 'S � Address - � • # <br /> - � License iVo. Z!'.Q Phone S"-7" 3141f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <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 <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public, ❑ Other ❑ Delta Depth of Grout Seal <br /> Type of Grout <br /> Irrigation �f -Approx..De ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ 'Type of Pump H.P. State Work Done <br /> Well Destruction" ❑ Well Diameter t Sealing Material (top 50'1 <br /> y <br /> Depth- w Filler Material (Below 50') <br /> TW,ZF OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet) +� ' <br /> Installation will Residence— Co� <br /> mmercial_ Other <br /> Number of living units: umber bedrooms r <br /> . Character of soil to a depth of 3-feet: y <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> `PKG. TREATMENT PLT, ❑ LA <br /> Method of Disposal <br /> Distance to neare Well tion Property Line <br /> f, <br /> LEACHING LINE ❑ No. & Length of lines } ; <br /> Tot h/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation 9 <br /> Prope e <br /> SEEPAGE PITS ❑ Depth Size Number f <br /> ,SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ { <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 lar <br /> rules and regulations of the San Joaquin Local Health District. ws, and <br /> Home owner or licensed agent's signature certifies the following: <br /> g: ��I certify that in the performance of the work for which this permit is issued, I shall not <br /> Y 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:"1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- y <br /> tion laws of C ornia." <br /> The applica m st call for all require i ction . Complete drawing on'Arse side: <br /> Signed 1 Title: <br /> DaT - <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by w – f <br /> Area <br /> Pit or Grout Inspection by Date Date Final Inspection by Date `6 <br /> Additional Comments: (/ <br /> ❑ Stk 466-6781 C] Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 <br /> FEE gMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CASH DATE VZ ; <br /> + EH 13-24 IREV.t i e 51 ��� �yi EH 14-26 < , <br />