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f` * - APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E 1601 E. HAZEL T ON AVE., STOCKTON, CA <br />`s 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 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 /> Job Address ` ,1 City �o Lot Size PM <br /> j Add Phone <br /> Owner's Na <br /> i h1. .� License No <br /> Phone l <br /> e Contractor _� Address <br /> TYPE OF.WELLL.PUNtP_-� , EW,WELL_I__1.__ �.� -__WELL REPLACEMENT„❑_.. .DESTR.U.CT.ION_❑_ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 111 <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> Llilndustrial --rE-.0pen-Bottomw^'�—E-Manteca —Dia:-'-of-Well-Excavation �” "^"�^ `"Dia"of Well Casing <br /> Specifications <br /> i <br /> ❑ Domestic/Private ❑ Gravel Pack _ ❑ Tracy Type of Casing S P <br /> ['1 Public i Ll Other F] Delta Depth of Grout Seal Type of Gout -1 <br /> I I I,Irrigation i. Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done _ $ :f <br /> Well Destruction ! ❑ Well Diameter Sealing Material Itop 501 l <br /> - s Depth Filler-Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I ] iNo septic system permitted it public sewer.,is <br /> available within 200 feet.)+' <br /> r, I <br /> I nstallation will `serve: Residence Commercial Other 111 <br /> Number of living units: Number of qedrooms i / q <br /> Character of soil to a depth of 3 feet: %— Water table depth <br /> ,-„SEPTIC TANK,-- +-_.._TP—Type/Mfg-- � -- - C� —Capacity-l�da No:-Compartments <br /> s.-PING. TREATMENT PLT:-0 Method of Di s sal I <br /> ^', "Distance to nearest; Well Foundations Property Line <br /> °• <br /> LEACHING LINE;”" -No;& Length of linesTotal'length/size <br /> FILTER BED a` w. ❑ Distance to-rkarest: Well Foundation Property Line ED '� I <br /> SEEPAGE PITS je.�, Depth —Size Nylmber <br /> SUMPS ❑ Distance to nearest: Well Foundation /n Property Line p <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance,with/San Joaquin county ordinances, state laws, and <br /> rules-and-repulations'af-thb-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-pe?son in such manner as to become subject to workman's compensation,lav+s,of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certif at 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 Californ' <br /> The applicant m t all for 'I equire spections. Complete drawing on re a side. + <br /> Signed X Title: Date: <br /> a <br /> f s FOR DEPA TMENT USE ONLY <br /> Application Accepted by } Datef Area <br /> ".1 <br /> Pit or Grout Inspection by t � Date 1z� "Final Inspection by�'- Date 9` 27 <br /> : > /^ <br /> Additional Comments: <br /> I ❑ Stk 466-6781�F _ ❑ L6di>369-3621 l ❑ Manteca 1823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return.all copies to: Environmetltal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> . <br /> S <br /> FEE A40UNTIDUE 'AMOUNT REMITTED8F1 RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> a,EH 13-24(REV."/K 5) <br /> EH 14-26 <br /> 1 <br />