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* APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 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 /> r <br /> Job Addressr V Cit <br /> Y ^ Lot Size PM <br /> Owner's Name ' Q ddrs .]/ /� <br /> i' Phone <br />' Contractor/=Z=8 L-icense No. 14 Phone CJ <br /> TYPE OF f WELL/PUMP: NEW WELL ❑ WELILLPLACEMENT ❑ � � DESTRUCTION ❑ <br /> r PUMP INSTALLATION)Q ~ STEM REPAIR Q � OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FL'D. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL) OTHER WELL PITS/SUMPS <br /> F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTfON'SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation_ <br /> I Dia. of Well Casing <br /> 14 ❑ Grave( Pack 11 Trac <br /> Y Type of Casing Specifications <br /> F1 Public ❑ Other i1 Delta Depth of Grout Seal <br /> Irrigation Type ai Grout <br /> I 1 Jr <br /> —.-Approx. Depth I 1 Eastern ` 1 <br /> Surface Seat installed by. <br /> RepairWork Done F1 Type of Pump H.P. <br /> State Work Done1 ,f n <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 50'? <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION I 1 DESTRUCTION f i o,septic system permitted if public sewer is }}} <br /> Installation will serve: Residence_ Commercial— Other a available within 200 feet.) /T <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: " <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg Capacity '� No. t' <br /> PKG. TREATMENT PLT. 1-1 � Compartments <br /> f <br /> Distance to nearest: Well Method of Disposal <br /> Foundation <br /> Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Total length/size <br /> Foundation Property Line <br /> SEEPAGE PITS <br /> I l De <br /> pth Size Number ' <br /> SUMPS __ Cl—Distance to nearest: - Well <br /> Foundation n!:77 " •Property Line <br /> DISPOSAL PONDS a ❑ -- <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 /> 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, 1 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 certifythat in the Performance of the work for which this permit is issued, I shall employ P <br /> tion laws of California." p y persons subject to workman's compensa- <br /> tion <br /> applican II require ons. Complete drawing on raver ide. <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE LY <br /> Application Accepted by Cf1 ' <br /> Date �(w <br /> ^ Area I <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 El 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 DUE AMOUNT REMITTED CK <br /> INFO CASH RE EIVED BY DATE PERMIT'NO. <br /> +-EH 13-24(REV,,inS> <br /> EH 14-213 <br />