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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> '1 \ 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Y1 Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N't► <br /> 1Complete in Triplicate) <br /> r <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 s <br /> I 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 '�` �� v$.•, C - Lot Size PM <br /> Owner's Name Address Phone <br /> License fVo.- Phone <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 FLD. PROP. LINE <br /> f _FOUNDATION_ AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE ,TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ <br /> ❑ Industrial ❑ Open Bottom" ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ,❑%Gra,lel Pack ElTracy Type of Casing Specifications <br /> 1­1Public [7Other { F1 Delta Depth of Grout Sea] Type of Grout <br /> I I Irrigationi I I Eastern Surface Seal Installed by <br /> �I * � 7 <br />€ Rep'air"Work,Oone- 0— {Type-of-P.0mp_ ; H.P. State Work Done <br /> f Well-.Destruction ❑, '.Well Diameter Sealing Material (top 501 <br /> o f <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is <br />+ vailable within 200 feet.) <br /> t installation will server Residence— Commercial_ Other <br /> Number of living units: -Number of bedrooms <br /> I :z 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 /> t <br /> LEACHING LINE ❑ No. & Length of lines Total.kength/site <br /> FILTER BED + ❑ Distance to nearest: -Well Foundation Property Line <br />�. SFEPAGE PITS I i Depth Size Number <br /> .SUMPS Ll 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 Lcical Health Dj%tfict.x f <br /> :Home owner or licensed agent's signature certifies the following: "I certify that in the"parformance 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 /> f !certifies the following: "I certify that in the performance of the work for which this permit is issued, I;rall•em_ploy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Co(llplete drawing on reverse side. <br /> ` # <br /> Signed X—x � W - �i�X94 Title: t9ev lig' A' Date: 0 !� e�F <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by -(2ne". „F..�.Data 3 `-' � ) Area q <br /> Pit or Grout fnspe`ctiian liy” ` " - _ Dain a Final Inspection by ��"" �-^G� Date , U� <br /> Additional Comments: K D - <br /> t EI Stk `486-6781 ❑ Lodi 369-)621 ElManteca 823-7104 V E) Tracy�835-63_85 <br /> I Applicant lieturn all copies to: Environmental Health Pe /Sery <br /> rmitices 16W1 E.Hazelton Ave.,P.O.Box 2009, Stk., CA 95201 <br /> FEE <br /> I <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> r.EH 13-24 fttEV.r/n 51 I innIt.� f <br /> EH 14-26 V�� f <br />