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i <br /> l APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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! oaquin 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 /> 'lZe'I'll A4/ <br /> Job Address / /(�al�r� ' G!+ City Lot Size PM <br /> 0ner's Nam A ss / Phone /� S <br /> til GJ as /10 !— <br /> Xoa tor License N Phone <br /> TYPE OF WELL/PUMP: i� W NEWELL ❑ WELL REPLAC WENT ElDESTRUCTION ElPUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 1F ' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA�fi6NS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifid9tions <br /> f'1 Public D Other ❑ Delta Depth of Grout Seal L Type of Grout <br /> I I Irrigation J ..Approx. tI I Eastern -Surface Seal Installed <br /> Repair Work Done ❑ Type of Pum ^"` H.P. j State Work Done �. . <br /> WellfDestruction ❑ Well Diameter Sealing�e Sealing Material (top 50'I � \ <br /> Depth J0�� Filler Material (Below 50') 1 ` __� <br /> 'TYPE OF SEPTIC WORK': -NEW,INSTALLATION I1 REPAIRlADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is J" <br /> available within' -feet'j 6 <br /> Installation will serve: Rediidence_ Commercial_ Other ," 'l ! <br /> Number of living units: L Number of bedrooms <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 l <br /> ' I Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ ' (Distance to nearest: Well IQ_ Foundation Property Line <br /> I � <br /> I , <br /> SEEPAGE PITS I I IDepth Size Number <br /> k, SUMPS LlIDistance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work wifl-tie done in accordance with San jo-aqui-(county ordihance'-ifate=ta`ws and-- <br /> j rules and regulations of the San Joaquin Local Health District. <br /> i Home owner or licensed ageks 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:Pplicar"LLst II f r quired inspections. Complete drawingon raver side.SignTitle: f Date: �'!III 7 � <br /> FOR DEPARTMENT USE ONLY t ` <br /> Application Accepted by II� ' ' i 'cj-�_ Date <br /> i • Pit or Grout Inspection by I�. Date Final Inspection by J Z Dater+ ' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Z.) <br /> Inn i­i <br /> Applicant- Return all copies`to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 < _ <br /> INFO AMOFEEQUNT DUE AMOUNT REMITTED ASH tK Ji__ RECEIVED BY [TATE PERMIT"No. <br /> ..EH 13.211REV.ti/65f T7J 7 A 9 <br /> 1 I�' <br />