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APPLICATION POR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />'r (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. <br /> Job Address City of Size PM <br /> K <br /> Owner's Name112 P Address Phone <br /> Contractorress wi License N Phone <br /> TYPE OF WEL /PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU TION ❑ <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 I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f <br /> ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F.-1 Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> l'I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> `1 TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION i I DESTRUCTION ! I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> vNumber <br /> Installation will serve: R 'dente± Commercial_ Other ^Number of living units: of bedrooms_ +- <br /> '� Character of soil to a depth of 3 feet: Water table depth i <br /> U SEPTIC TANK 0 Type/MfgCapacity -: f7 No. Compartments A <br /> S. <br /> PKG. TREATMENT PLT. LJ � -_� € Method of D osal <br /> Distance to nearest: --, Well Foundation s-L Prop;rty_Line <br /> LEACHING LINE 0 No. & Length of lines # <br /> 9 � � � Total length/size <br /> 71) <br /> FILTER BED ❑ Distance to nearest: s Well/ -I-, Foundation h-10 0 Property Line <br /> SE GE PITS 1 1 Depth Siza Number r <br /> UMPS Ll Distance to nearest: Well_ Foundation_too Property Line <br /> DISPOSAL PONDS ❑ <br /> r <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 Di§trict. kyr <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 I <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." <br /> The applicant U call for all re r d i spections. Complete drawing on sesside. <br /> Signed X Title: � Date: <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date J12 t9 Area <br /> 4 r <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: i \ <br /> 0 Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 j�t_\Vn`�!n <br /> \�j� v 4 <br /> INFOFEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. /w' <br /> r EH14-ZgIREY.I/K51 � <br /> .uU �r/ <br />