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V� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601, E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> s (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. 1852 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address S d <br /> City O gzmx Lot Size PM <br /> Owner's Na - Address <br /> 20 <br /> Phone <br /> Contractor Address <br /> TYPE OF WELL/PUM License No. Phone L� I <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER <br /> SEWER LINES DISPOSAL FLO, PROP. LINE <br /> a; ! FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Indu—strial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> f ❑ D�mesti67Private ❑ Gravel Pack Dia. of Well Casing (� , <br /> ❑ Tracy T V� <br /> ❑ Public Type of Casing Specifications <br /> ❑ Other .❑ Delta Depth of Grout Seal (((��� <br /> _ <br /> i <br /> 11 Irrigation App�ox. Depth, El Eastern t t� Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done D Type,of`Pump H.-P. <br /> Well Destruction O Well Diameter State Work Done <br /> _ ._ Sealing Material {top 50'} <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT <br /> INo septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial, Other table within 200 feet.) <br /> Number of living units: <br /> = g I Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> 4 ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT. ❑ No. Compartments <br /> Distance to nearest: WeH Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines �' -4. <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: �Welf: ''� <br /> Foundation F Property Line <br /> SEEPAGE PITS f Depth <br /> Size Number <br /> SUMPS Distance to nearest: Well af "- <br /> -� Foundation, ,DISPOSAL PONDS41' <br /> p - .,, , x TM 4 Property Line <br /> I herebycerci _ � <br /> certify that i�tiade 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: ` <br /> employ any person in such manner as to become subject to Workman's comtpensation lhat in the aws-of Califonce rnian"Contractowork for r'sih ring or sub-ch this contracting t is nglsignaltnot <br /> ura ; <br /> certifies the following."I certify that in the performance of tFie°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 call for all re uired inspections. Complete drawing on reverse side. <br /> Si d <br /> Title <br /> Date: _ <br /> FOR DEPARTMENT USE ONLY <br /> ,. .......-...�...._..�...- -rJ CJ <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date <br /> Final Area <br /> by Date —/.7`ep�o <br /> Additional Comments" P .R C��� Zz <br /> ❑ Stk 466 6781 ❑ Lodi. 369 3821 El Manteca 823-7104 <br /> Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazelton Avg e,PP.O. Box 2009 tk., CA 9520 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY DATE PERMIT"NO, <br /> + EH1 -24SREV.i/e51 <br /> EN 144-18 <br />