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APPLICATION FOR PERMIT y ' <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 /> 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 /> �} f <br /> Job Addressr ��rnQ l E <br /> �p� City Lot Size PM <br /> Owner's Name !'..' r+t1• �� Address v""' T ���11Q <br /> Phone 17y3-' <br /> Contractor Address <br /> License Na. Phone_ <br /> TYPE OF WELL/PNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation --Approx. Depth I ) Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Hone _ <br /> Weil Destruction ❑ Well Diameter Sealing Material (top 501 r <br /> Depth Filler Material (Below 50') IU{yi <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION 12QN0 septic system permitted if public sewer is C1 <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: f Number of bedrooms 3 <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 /> t Distance to nearest: Well Foundation Property Line <br /> F � . <br /> I <br /> LEACHING LINE ❑ rNo. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i l ,,Depth Size Number <br /> SUMPS ❑ t Distance to nearest: Well Foundation Property Line <br /> r DISPOSAL PONDS ❑ (g� <br /> 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 Di§trict. <br /> k 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m a for all <br /> ,relquir inspections. Complete drawing on reverse side. <br /> Signed X w• dg� <br /> k 9 Title: t.(l Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ZZ Area 4LIL <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ iracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br /> +.EH 1 -21(REV.l/H 5) <br /> EH 114-28 ��l -'�•�.1— <br />