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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 I <br /> i <br /> PERMIT EXPIRES 7 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. ,. car a r' 1/�el y7Z S"4 k <br /> r 4-?6.3 -W)Lot SizetZ Qy r PM <br /> Job Address -� �� city <br /> Owners flame ■` " Address `''�` `� P6one 36 ^` <br /> VZ— <br /> Contractor ��-+� * Address r- Li se Nol- &Phone <br /> "7 <br /> TYPE OF WELLIPUMP: 'NEIN WELLV WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLAT SYSTEM REPAIR ❑ OTHER ❑ , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTEND USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI IO It <br /> Dia. of Well Casin <br /> ❑ Ind lal ❑— Op ottom F1 Manteca Dia. of Well Excavg <br /> omestic/Private ravel Pack ❑ Tracy Type of,Casing S Specifications` 'O' <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �4 <br /> ❑ Irrigation —.Approx.mp D t Eastern Surface Seal Installed by <br /> G <br /> Repair Work Done ❑ Type of PuH.P. 3 - State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 I <br /> i <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 20O feet.) <br /> 1 <br /> Installation will serve: Residence_ Commercial_ Other <br /> 5 <br /> Number of living units: Number of bedrooms <br /> depth <br /> de <br /> table Water ae p <br />'k Character of soil to a depth of 3 feet: Q � <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. L] Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ;❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation . Property Line <br />` SEEPAGE PITS ❑ -Depth ` Size Number <br /> SUMPS ❑ Distance to nearest:, Well Foundation Property Line <br />' DISPOSAL PONDS ❑ <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 /> employ any person in such m r as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following: "I c fy th in tha.I performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion lawsof C 'forr <br /> The applic t s all r I eq re ins i s. Complete drawing on rely 1 <br /> .J 23 Ott <br /> Signed Title: (l!! 11� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Acceptedbya^^ Date `g�GArea v` <br /> ' Pit o Grou Inspection by r Date .Z� inal Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 fi385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO J 2 X77 1 <br /> + EH 13-241REV.1/8 5) /015.00 <br /> EH 1428 <br />