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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA r <br /> Telephone (209) 466-6781 <br /> 1 <br /> PERMIT EXPIRES 9 YEAR'FROM DATE ISSUED" ' <br /> w (Complete in"Triplicate) <br /> IC <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. y. ' <br /> Job Address m <br /> CityLot Sized PM ' <br /> Owner's Name ;i. Y' <br /> i r,i,'Address <br /> hone <br /> Contracto # _,.-_ --� _-. ... . <br /> Address ' <br /> TYPE OWELL/PUMP: <br /> ' 6 i 0 -?11Ftlu License No.- Oc Phone <br /> NEW WELL Q WELL REPLACEMENT ❑ ' DESTRUCTION ❑ <br /> ­P_UMPiINSTALLATiON""❑A.� .1 SYSTEM-AFFAIR,"p- .�.� <br /> DISTANCE TO NEAREST: SEPTIC TANK - OTHER'❑- "---- - <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL u <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> a <br /> ❑ Industria! ❑ Open Bottom Q Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack ❑ Trac <br /> 12 Public y Type of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> El Irrigation Approx. Depth ❑ Eastern Type of Grout <br /> ---Approx. Surface_ Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter State Work Done <br /> Sealing Material (top 50') S <br /> Depth Filler Material fBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is G <br /> Installation will serve: Residence I,-*, Commercial_ Other available within 200 feet.) <br /> Number of living units:__/— • Number edroo 's TT <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK21"-Type i Water table depth 1 '� <br /> /Mfg - �d <br /> PKG. TREATMENT PLT. El Capacity No. Compartments <br /> Method of Di�posal <br /> Distance to nearest: Well <br /> Foundation-A0- property Line <br /> ' F- <br /> LEACHING LINE C�No.'& Length of lines 40 Y �W.y <br /> FILTER BED - — "�>�,. Dotal length/size O <br /> Distance to nearest: Well�� Foundation <br /> .Property Line�� <br /> SEEPAGE PITS Depth 1Size <br /> SUMPSDi -�- rNumber <br /> ❑ stance to nearest: Well <br /> Foundation,t6--PL6P e <br /> DISPOSAL PONDS ❑ - rqy Line <br /> f � <br /> ` ,f -,•1-herab'"y_66hify_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 certi %that in the performance of the work for which this permit is issued, I shall not <br /> A 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 /> J-'"'�"'ce`rtifias the 1`6116 ring:"I certify that in the performance of the Work for which this permit is issued, I shall eoy persons subject to workman's compensa- <br /> 1 `� d mpl <br /> tion laws of California"'%- <br /> Tha appElcant,must call\for req 'ad inspections. Complete drawing on reverse 'de, <br /> 1 <br /> ,Signed r <br /> Title <br /> : � Date: r <br /> FOR DEPARTMENT USE ONLY" <br /> Application Accepied byGr i <br /> Date OJ Area <br /> Pit or Grout Inspection by #€ Date <br /> Final Inspection by Date <br /> Additional Comments: l <br /> ❑ 5tk 466 6781. ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 <br /> �, <br /> Applicant- Return all, pies-to:�Envirogmental.Health Perhifi/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 35201 <br /> FEE gMOLINT.DUE AMOUNT REMITTED CK* <br /> ! <br /> INFO CASH RECEIVED BY DATE PERMIT"NO- <br /> i <br /> + EH 13-24(REV.t/E51 �,- ! <br /> EH 1428 't dK h1 <br />