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APPLICATION FOR PERMIT <br /> -. -20" <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> y 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED n <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 /> 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 /> r J LOO a ut_e + PM d <br /> Job Address � <br /> f !��r�'-• City r�e "°�-_• Lot Size,', . <br /> Owner's Name. Address Phone <br /> Contract t o Address License No.,728 Z-_Z-'(& Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 6 <br /> PUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ r ti, OTHER ❑ , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDPROP. LINE <br /> r, <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ;INTENDED-,USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> ❑ Industrial f ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Gravel'Pack ❑ Tracy Type of Casing Specifications ' <br /> ❑ Public ❑ Other '*- tel❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation __Approx. Depth,� O-Fasfern " a-,Surf acd Seal,Installed by <br /> f.ac. <br /> ❑ ..a�• r r w..kz r N <br /> Repair Work Done Type of Pump `. H.P�"� State Work'-Done <br /> t <br /> Well Destruction Ll Well Diameter Sealing Material (top-50') _ _ <br /> Depth Filler Material (Below 50'I F _- �'�?s K 51 �?s `} a, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR ADDITION e DESTRUCTION,i] (Norseptic.system-permitted if public sewer'is U1 <br /> available within 200 feet.),p d <br /> Installation will serve: Residence Commercial_/ Other <br /> Number of living units: c9 Number c b droom <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 /> Distance to nearest: Wall'-_ Foundation_ ..Property Line. <br /> LEACHING=LINE- ❑ No. & Length of lines Total length/size i, `' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' <br /> e SEEPAGE PITS 5?"'Depth s Size _-Number <br /> SUMPS LJ Distance to nearest: Well 1�ra r Foundation�d Property Line ` <br /> DISPOSAL"'PONDS• ❑ <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 /> tion laws of California! <br /> The applica ust call for Tfligredspections. Complete drawing on reverse side. <br /> Signed Yitle: y • �� Date: -Q <br /> k <br /> FOR DE ARTMENT USE ONLY- <br /> l Application Accepted byDate 'Area <br />{ � <br /> Pit 57 <br /> r Grout Inspection by ate 4inal Inspection by _ Date 7� <br /> Additional Comments: <br />[ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 . ❑ Tracy 835-6385 <br />`l <br /> -,,Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201. <br /> �s <br /> FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT•NO. <br /> INFO CASH <br /> + EH13-24IREV.I/B51 - .�.. ti�-.ITco iR� 4-7-7EH 1426 .�, <br /> f <br />