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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <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. <br /> /V i City J Lot Size PM <br /> Job AddressS2 <br /> `^ 4 l�1 Phone ` <br /> Owner's Name Address , <br /> DLJ! �y Phone_ v <br /> Address dt/ License No. <br /> Contractor <br /> TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT LJ DESTRUCTION ❑ <br /> ,PUMP INSTALLATION ❑ SYSTE R ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE LL -OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NST CTION SPECIFICATIONS <br /> ❑-Industrial ❑ Open Bottom ❑ Manteca`-1,' Dia. of ell Excavation Dia. Well Casing <br /> ` ._ _.:FT e f Casing Spefifications <br /> 0 Domestic/-Private ❑ Gravel Pack ❑ Tracy YP g <br /> f-1 Other _:--n-D" to - + De 'of Grout Seal Type of Grout <br /> r'1 Public e4 <br /> I } Irrigation 4�.Approx Depth I 1 EastA�n~ 'S ace Seal-46stalled by - <br /> + ; <br /> I State Work Done I <br /> - Repair Work Done 13 Type of Pump R H. <br /> Well Destruction ❑ Well Diameter E Sealing Material atop 50'1 <br /> Depth., Filler Material IBelow 50=)---° - -- <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION f REPAIR/ADDITION I ! DESTRUCTION I 1 {No septic system permitted if public sewer is <br /> :--- available within 200 feet.I <br /> Installation will serve: Residence= Commercial I Other <br /> Number of living units: Number of bedrooms_— <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TAMC ❑ Type/Mfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 € ,� /� Method of Djsgos <br /> s �!/ aIJ <br /> "_Distance to nearest: Well undation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines r " To ! length/size <br /> � '`°'FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth ' kst <br /> Size Nu b s <br /> SUMPS ❑ Distance to near : Wel! Foundation PVmp �yine <br /> DISPOSAL PONDS ❑ ~, ,' f <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 Di§trict. <br /> certify that'in the performance of the workJarwhich this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I ca y <br /> 9 <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: "!certify that in the performance of the work for whichAhis permit is issued, I shall emplo ns subject to workman's compensa- <br /> tion laws of California." <br /> ` a. 4 <br /> The applicant st colt for purred in ctions. Complete drawing on reverse side. _ <br /> r9 <br /> Signed Title: �" - Date: � <br /> 9 <br /> s <br /> D FITMENT USE ONLY <br /> Application Accepted byD4�V� Date ""v " Area <br /> Pi or Grout Inspection by Date Final Inspection Date <br /> �J: <br /> Additional Comments: y 1 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;Stk, CA 95201 <br /> FEE AMOUNT <br /> INFO DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT'NO. <br /> TT <br /> V r <br /> +.EH13-24tREV.t/n5) <br /> EH 14-26 <br /> } <br />