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APPLICATION .FOR PERMIT <br /> s SAN JOAQUIN LOCAL HEALTH DISTRICT �. <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781, t <br /> PERMIT EXPIRES_1 YEAR FROM DATE ISSUED <br /> ' a (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 r �O City Lot SizePM <br /> 4 Owner's Name' U?�� Address vs Phone <br /> Contractor L6E� u Y�L� L' Add License No �Phone 7 d s <br /> TYPE OF WELL/PUMP: y NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION :❑ SYSTEM REPAIR ❑ p OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC,TANKr - - SEWER LINES' DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELLw _O.T.HI;R WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial +❑ Open-Bottom❑ Manteca Dia�lof Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications❑ Public EJ ❑ Delta Depth of Grout Seal ! Type of Grout <br /> ❑ Irrigation __±Approx--Depth—❑-Eastern—3urfawSeal-installed by € <br /> Repair Work Done ❑ Type of Pump H.P. i State Work Done <br /> Well Destruction ❑ Well Diameter, Sealing Material (top 501 <br /> " <br /> 11� — —Depth s d Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION ❑ (No septic system permitted if public sewer is <br /> - I ; available within 200 feet.) <br /> Installation will serve: Residence L�Commercial— Other <br /> Number of living units.--,/— Number of bedrooms 731.4 „? <br /> Character of soil to a depth of 3 feet: O F Water table depth <br /> j' SEPTIC TANK IOType/Mfg Capacity 1 No. Compartments <br /> f PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: fell Foat' n= Property Line <br /> V % <br /> LEACHING LINE 1 ��f�o & Length of lines - •�" ` '" w Total'',length/size <br /> + FILTER BED <br /> '. M1 ❑ � Distance to nearest: Well� - 'Foun'dation .�5' Property Line <br /> 4 <br /> 3 <br /> SEEPAGE PITS yL_,1:Iepth� Size L4 K Number r- <br /> SUMPS i ❑ Dista j e to nearest: `' Well Foundation Property Line '' s <br /> DISPOSAL PONDS i ❑ <br /> I hereby certify that 1 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 /> emkjloy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certi4a, he following:"I c ify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> k, tion laws o alifornia." <br /> The applican mu II for all quiz d ins tions lete drawing on arse std e <br /> Signed itle: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date 4?'a-A Final Inspection by; Date <br /> Additional Comments: <br /> ---E-Stk-466=6781—p-L-adi^-+36g=3621--O-Manteca--823--7104—A;"O-Tracy-835=6385- .l <br /> Applicant- Return all copies to: Environmental Health Permit/Services"1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> HEf <br /> INFO AMOUNT DUE4 -0­7 <br /> AMOUNT REMITTED CC4K8H RECEIVED BY DATE PERMIT`NO. ;r <br /> + EH131429 24(REV <br /> EH .1/e5) 470 - �/�` [ �•f�`-' rp / <br />