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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (200) 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 /> Job Address ) City Size PM <br /> wo�� <br /> Owner's Name Phone <br /> Contractor ane <br /> TYPE OF WELL/PUMPf. NEW WELL LD WELL REPLACEMENT ❑ ESTRUCTION ❑ <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 r ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well (Destruction ❑ Well Diameter Sealing Material (top 501 r� <br /> Depth Filler Material (Below 501 0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLA EPAIR DDITION ❑ DESTRUCTION (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 s No. Compartments <br /> x <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> { tan to rW t: Well Foundation Pronerty Line <br /> LEACHING LINE ❑ No. & Length of line r Total length/si <br /> FILTER BED ❑ Distance to nearest: We11 Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <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 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 all quir i pecti ns. Comple ling on v side. <br /> Sign( Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by L� Date rea <br /> Pit or Grout Inspection byjr. <br /> Date t Final Inspection byAJP, Date <br /> Additional Comments: / <br /> �5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 / <br /> INFO <br /> EEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24 IREV.1/e 6) ` ' ��/�y SN, 5-9 <br /> EH 1426 ales <br />