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t APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 Q "*`Y/ Lot Size PM <br /> t <br /> Owner'sName Address e <br /> Contrac Addres JIF 4a Licenst14Phe ; <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 F ROP. LINE <br /> FOUNDATION AGRICULTURE WELL R WELL PIT5ISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ eca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public F Other Ll Delta Depth of Grout Seal Type of Grout . <br /> I I Irrigation —_A ox. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ e of Pump H.P. State Work Done <br /> Weil Destruction Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l 1 DESTRUCTIO No septic system permitted if public sewer is <br /> available within 200 feet.I <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 Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line q <br /> SEEPAGE PITS I 1 Depth Size Number *ti <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." - z <br /> The applica t ust call for all required in ctions. omplete drawing on rev a side. <br /> Signe Title: �'� �� Date: , 3— <br /> ._. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by VDate 1--s Area <br /> Pit or Grout Inspection by 1-01 Date Final Inspection by ' Date.,.... <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 2009, Stk., CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �}PERM/IT'NO. <br /> t EH 13.24IREV.tiH51 ��` � ,�-Iola <br /> EH 14-2e J D 1 <br />