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_ APPLICATION FOR(PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781, ` r,. 3 -Vtel? <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - <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. i;, "i� 4 . . <br /> Job Address I CJ �a/� r City C ---1'6t Size PM <br /> Owner's Name r <br /> 6tAddressPhone v <br /> Contractor ��` ssQ License No. + ! Phone! <br /> TYPE OF WELL/PUMP: NEW WEW❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> k >+ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES 0 ISPOSAL FLD. PROP.-LINE, , <br /> rFO.UNDA IbN�AGRICULTURE"WELL' --�OTHER`WEI:L��PITS/.S_C1MPS <br /> INTENDED USE e *TYPE OF WELL M AREA C TRUCTION SPECIFICATIONS <br /> ❑ Industrial i ❑ Open Bottom ❑ Manteca ia. f Well Ex66atfan Dia:of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack iQ] Tracy Type o Specifications <br /> El Public LJ Other k❑ R [�epth of Grout a Type of Grout <br /> i ❑ irrigation ">­-�gpprox. Depth Eastern Surface Seal Instaiied by fes' T <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 (Belo 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONET,gUC �N (No septic system permitted if public sewer is <br /> �``++YY 1C'rCC ,,available within 200 feet.) <br /> Installation will serve:.-Residence Commercial— Other s t <br /> Number of living units: Number of bedrooms,;f <br /> Character of soil.to a depth of 3 feet: Water table depth , <br /> SEPTIC TANKType/Mfg Capacity fNo(Compartments <br /> PKG. TREATMENT PLT7Y 1 .ov- Method of Disp al <br /> �.,.maistance to,neare_ Well4 Foundation Property Line <br /> tg -kx <br /> LEACHING17- <br /> LINE :� No. & Length of lines Total length/size - f <br /> t <br /> FILTER BED ❑ Distance to nearest: _We t'—,, Foundation Property Line <br /> r <br /> SEEPAGE PITS 1J Depth Size Number l <br /> SUMPS ❑ Distance to nearest: well Foundation Property Line <br /> DISPOSAL PONDS ❑ """' "" '" <br /> I hereby certify that( have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulationspf the San Joaquin Local Health District. �r k <br /> Home owner or licensed agent's signature certifies the-following: 'kl certify that in the performance of the work,for)which this permit is issued, 1 shall not <br /> employ any person in, uch manner as to become subject to workrrian's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followings"I certify Uiaf 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 applican ust ..for all quired in ctions. Complete drawing.on fr-e-v�er��se side.- <br /> , <br /> SignedTitle:, C) LfkD rlT (fes Date: <br /> FO D ARTMENT USE ONLY <br /> Application Accepte by Date ��'Lz�/ Area r <br /> Date final Inspection b Date --L�i7 <br /> Pit or Grout Inspe y y <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3511 ❑ Manteca 823.7104 ❑ Tracy 835-6385 P�"o�«'� <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.;.CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVER BY DATE PERMIT NO, ... y <br /> + EH 14-24 IflEV.I/e s l <br /> EH 1429 � � ® � / � <br />