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APPLICATION FOR PERMIT Ir=S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 Ci <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/of install the work herein described. This application is <br /> made incompliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wev pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address00-1 <br /> Owner's Name <br /> ress �"�`; ��,�"'� Phone <br /> .Y! Address License No. One <br /> Phone_ <br /> Contractor -" <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION"❑"` <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER 11 <br /> i SEWER LINES DISPOSAL FGD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CATIONS pia of Wel! Casing <br /> h ❑ Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> 171 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout — <br /> l"1 Public Cl Other Cl Delta Depth of Grout Seal <br /> I 1 Irrigation Approx. Depth l I Eastern Surface Seal Installed by !~ , <br /> r H p State Work Done <br /> Repair Work Done El Type of Pump ti <br /> Well Destruction ❑ Wel! Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> ti <br /> TYPE OF SEPTIC WORK: NEW INS TALLATION I 1 REPAIR/ADDITION l 1 DESTRUGTIO setic system <br /> thin 200 feet.') if public sewer iA <br /> 1 r 'Installation will serve: Residence Commercial Other v <br /> :; CNumber of living units: Number of bedrooms } <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK CI Type/Mfg Capacity No. Compartments <br /> f1 I Method of Disposal 1 <br /> PKG. TREATMENT PLT. ❑ € <br /> I <br /> Distanc;to nearest: Well Foundation Property Line <br /> Total lengthtsize <br /> LEACHING LINE LINo. & Length of lines <br /> FILTER BED ❑ Distance to_nearest: Well Foundation Property Line <br /> Number <br /> SEEPAGESEEPAGE PITS I I Depth I Size <br /> SUMPS L1 Distance to nearest: Well Foundation - Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that 1 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 Diltrict. <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, 1 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.,' !j <br /> The applica call for all require i pections. Complete drawing on reverse side. <br /> l Title: s � Date: <br /> Signed X <br /> � i FdR DEPARTMENT U3E ONLY <br /> � Date Area <br /> Application Accepted by <br /> w� \41 042,6 Date } <br /> 1. Pit or Grout inspection by Date Final Inspection by <br /> Additional Comments: <br /> F ElStk 466-6781 ❑ Lodi 369 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. HazeltonAva;, P.O. Box 2009, Stk., CA 95201 <br /> lCK <br /> FEE AMOUNT 6UE AMOUNT REMITTED CASH RECEIVED BY ' DATE PERMl7'ND. <br /> INFO <br /> +. <br /> EFL 13.24(REV.1/n 5) .�� <br /> EH 14-26 <br /> l ' <br />