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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,.' <br /> VE.,:STOCKTON, CA <br /> 'Telephone {209) 466-67.81 <br /> PERMIT EXPIRES'1 YEAR FROM DATE ISSUED <br /> ., ,. ,r.lComplete 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 made H 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. PP tion is <br /> - o i O. Fy.. - i <br /> Job Addressa- <br /> x <br /> city "'Lot uC / "'Lot Size X .�✓1 PM i <br /> Owner's Nam Address 7 c� <br /> C° `L �{l�tJ Cid ` Phone t`n '� 79 �'S- <br /> Contractor Address <br /> TYPE OF WELL/PUMP: License No.-���phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUM TION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PR <br /> FOUNDATION AG TURF WELL <br /> 0 fjjPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> ❑ Industrial UCTION SPECIFICATIONS <br /> ❑ Open Bottom Ela Dia. of Well tion <br /> ❑ Domestic/Private ID Gravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing <br /> Cl Public ❑ Ot ❑ DeltaDepth Specifications <br /> Su' <br /> ❑ Irrigation �Approx. Depth ❑ Eastern Type of Grout <br /> j. rf_ace.5Gearout Seal1.installed by <br /> Repair Work Do ❑ Type of Pump <br /> H.P. State Work Done_ <br /> Wel! De ction ❑ Well Diameter Sealing Material Itop 50'1 t� <br /> Depth - Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITfON ❑ DESTRUCTION {No septic system permitted if public sewer is <br /> Installation will serve: Residence CommercialOther available within 200 feet.} <br /> �� ` <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3­feetw­- --��� <br /> SEPTIC TANKUUater table depth (14 <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Capacity-. No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE Cl No' & Length of lines ,.. . <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line E <br /> SEEPAGE PITS ❑ Depth 1 <br /> Size _ Number F <br /> SUMPS ❑ -Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation Property Line <br /> r <br /> I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ander <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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 must all for all required in '15 <br /> ions. Complete drawing on reverse side. <br /> Signed X - <br /> Title: Date: " /7`,:�> <br /> I . <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by /��� 1 <br /> Date Area 03 <br /> Pit or Grout Inspection by - Date '"•'� � _ -�_ <br /> Final Inspectionon by by Date <br /> 2 Additional Comments:7 ❑ Tracy 835.6385 . <br /> ❑ Stk 466-6781 ❑ adi 3621 Q? Ma�nteca237104 <br /> 7 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 7 <br /> - FEE AMOUNT DUE CK <br /> (NFO _ AMOUNT REMITTED H RECEIVED BYjDATEPERMIT NO.EH t3-24(REV.s i n s) • .. _ ._ l 41 .. ,-75-77 r N36 <br />