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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZEL.TON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Application is heteby 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 />PM ,_., „,....._..... <br />Owner's Name Address Phone <br />Contractor Address License No. Phone _ <br />TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 <br />PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 <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 />0 Industrial 0 Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br />CI Domestic/Private 0 Gravel Pack D Tracy Type of Casing Specifications <br />11 Public D Other n Delta Depth of Grout Seal Type of Grout <br />I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br />Repair Work Done 0 Type of Pump H.P. State Work Done <br />Well Destruction 0 Well Diameter Sealing Material (top 50') <br />Depth Filler Material (Below 50') <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 0 Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. 0 Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE El No. & Length of lines Total length/size <br />FILTER BED 0 Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS I I Depth Size Number <br />SUMPS 0 Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS o <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 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 must call for all required inspections. Complete drawing on reverse side. <br />Signed X Title • Date. <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by Date Area <br />Pit or Grout Inspection by Date Final Inspection by Date <br />Additional Comments• <br />Stk 466-6781 El Lodi 369-3621 0 Manteca 823-7104 El Tracy 835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. HazeIton Ave., P.O. Box 2009, Stk., CA 95201 <br />Lot Size <br />+ EH 13-24 (REV. 1/ n 5 <br />EH 14-26 <br />FEE <br />INFO <br />AMOUNT DUE, <br />r <br />OUNT REMITTED CK # <br />CASH RECEIVED BY DATE PERMIT . NO.