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APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> u <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) i <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. i <br /> Job Address <br /> k/ City Lot Size V` " rPM"`"��./// <br /> / - <br /> Owner's Name <br /> ress Phone <br /> Contractor ddress i se No. Phone <br />' TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ll <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 L1 Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F ' Type of Casing Specifications <br /> © Domestic/Private El Pack El YP 9 <br /> I' l'1 Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout <br /> l I I Irrigation -Approx` Depth l I Eastern Surface Seal Installed by- <br /> Repair <br /> y Repair Work Done L-1Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth # Filler Material (Below 50') -- <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION €r RE=PAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> �» available within 200 feet.) e" <br /> Installation will serve: Residence Commercial._ Other tJ" <br /> Number of living units: Number of berooms' <br /> Character of soll to a depth of 3 feet:" <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> 1 PKG. TREATMENT PLT. ❑� ^ ti Method of Bitsposal <br /> 140 <br /> Distance-to nearest: Well Foundation Property Line <br /> LEACHING LINE l ❑ No. & Length of lines i Total length/size <br /> FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line <br /> r <br /> SEEPAGE PITS rf I 1 Depth - Number <br /> UMPS ❑ Distance to nearest: Well ._ Foundation Property Line <br /> 1 DISPOSAL PONDS ❑ r '� <br /> i <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 laws, and <br /> rules and regulations of the San Joaquin Local Health Di'ltrict. <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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must c 11 for all req nspections. Comp) a drawing on re=- <br /> Title: _ Date: <br /> Signed X - <br /> r - <br /> r i. PARTMENT USE ONLY g <br /> f <br /> -, <br /> Application Accepted by epDate r Area <br /> 427e_ <br /> I. Pit or Grout Inspection by Date Fina! Inspection b Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ 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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> y _ L <br /> F t.EH 13-24iREV.ii85l O . <br /> � � s <br /> EH t4-2e <br />