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` APPLICATION FOR PERMIT <br /> l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTO,N, CA <br /> 1e Telephone,(209) 466-6781 <br /> _ PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applicatidn 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 /> 3 City F Lot Size PM <br /> Job Address ~ � <br /> �t`[/ ! [ �['�t!{`11�f► �1 3 tN• � Phone �J� g" �[S <br /> Owner's Name Addres <br /> " Contract r <br /> UCdt3l'ess License N Phone_ <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT LJDESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L3OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - d PROP-'LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Y ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia-'of Well Casing <br /> ❑ Domestic/Private D Gravel Pack - ❑ Tracy Type of Casing Specifications Q t <br /> C1 Public Ll Other n Delta Depth of Grout Seal Type of Grout J <br /> I I Irrigation Approx. Depth i 1 Eastern Surface Seal Installed by f - <br /> -Repair Work Done ❑ Type of Pump H.P. State Work Done_ 1" <br /> ii <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 - <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION LI DESTRUCTION i I (No septic system permitted if.public sewer is <br /> 'available within 200 feet.) <br /> Installation will serve: Residence_L Commercial Other' V '" <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ` Water table depth <br /> SEPTIC TANK ElType/Mfg Capacity ®' No'CompartmeiSts <br /> 2• <br /> PKG. TREATMENT PLT. ❑ kh <br /> �'f S.° e ,Method of Disposal <br /> Distance to nearest: We Foundation Property <br /> i <br />" LEACHING LINE ❑ No. & Length of lines k Total length/size t <br />'{ FILTER BED; ❑ Distance to nearest: Wel datior7 r Property Line <br /> SEEPAGE PITS I th �,�7� /7��-Size Number k <br /> S <br /> SUMPS �L Z Distance to nearest: Well, Foundation Property'Line <br /> DISPOSAL PONOS ❑ * <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, l shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contracttir'S hiring pr.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 st call for all qu irak inspections. CorT1pI9t49 drawing on reverse side. Dattao <br /> Signed X Title: M1 : <br /> R D RTMENT USE ONLY ' y <br /> Application Accepted by T Date <br /> Pit or Grout Inspection by Date Final Inspec' n by Date <br /> Additional Comments: <br /> L ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ' l❑ Tracy 835-6385 <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f <br /> FEE PUNT DUE AMOUNT REMITTED CCAKS# <br /> H RECEIVED By DATE PERMIT'NO. <br /> +.ER 13-241REV.I/ o �. a �V O [.C�+ LI �✓ / <br /> EH 14-2$ <br />