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+� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> � 1601 E. hIAZEL i ON AVE., STOCKTON, C <br /> Telephone (209) 466-6787 2, <br /> PERMIT EXPIRES 1-YEAR FROM DATE UUED <br /> k (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. `�r /� <br /> Job Address '-' <br /> lJ (_i F{� <br /> City Lot Size PM <br /> I <br /> Owner's Name A--tht5eha Address <br /> `_1 Phone <br /> r Contractor -► `L. ( Address S _ ! License No.q,3okli_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 /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> �.Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Grave( Pack ❑ Tracy Type of Casing <br /> "" - � Specifications <br /> 1"1 Public Cl Other Ll Delta Depth of Grout Seal <br /> ' <br /> i I Irrigation Approx. Depth (RI Eastern Surface Seal-Installed by Type of Grout <br /> Repair Work Done ❑ Type of Pump --H,.P. _ _ State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 56 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I.1 DESTRUCTION I o Septic system permitted if public sewer is <br /> � } available within 200 feet.) <br /> Installation will serve: Residence 4JConlmercial_ Other kA <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ' # Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> _ Method of Disposal <br /> Distance tri nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> ? 7otallength/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS 11 Depth Size ` <br /> Number <br /> SUMPS L1 Distance to nearest: Well Foundation <br /> Property Line <br /> DISPOSAL PONDS Lf —,,,,,„ <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 /> ti�app;li <br /> of Galifor ' <br /> Tm st call ai equir i s. Complete drawing on reverse side.S /—'1 � � `�a <br /> Titles. Date: '� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dat �� �$h <br /> Area <br /> Pit or Grout Inspection by W Date^ _ Final inspec'on by �� '�7 } <br /> Date G <br /> Additional Comments:: Date_ <br /> X678 — © Lodi 3&21Manteca 823- 104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: En al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED 8Y DATE PERMIT'NO. <br /> + EH 13-24(REV. <br /> EH 14-20 - J _ li\tl- <br />