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APPLICATION FOR PERMIT <br /> l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 /> Job Address <br /> City s�4 Lot Size PM <br /> t Owner's Name t' t J� 4 <br /> Address <br /> Phone , <br /> ! � Y.�.. , - - - . <br /> (� Address O y _ <br /> Contractor _�_. _ _- ---- <br /> Licert No. -.r� Phone p' <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> f DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE 6F:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial «�,❑ Open Bottom ❑ Manteca pia. of Well Excavation <br /> ❑ Domestic/Private C!'Gravel [sack _ Dia. of Well Casing <br /> ❑ Tracy Type of Casing Q <br /> E'1 Public Specifications <br /> f7 Other Cl Delta Depth of Grout Seal <br /> I 1 IrrigationA Type of Grout <br /> pprastern S <br /> ox. Depth 1.! Eurface Seal Installed by <br />! Repair Work Done 0 Type of Pump E i H p <br /> I State Work Done_ <br /> rWell Destruction Q Well Diameter Sealing Material (top 50'I <br /> Filler Material IBelow 50') a.- <br /> r TYPE OF SEPTIC WORK; NEW INSTALLATION _ REPAIR/ADDITION I I DESTRUCTION I I iNo sept1C system permitted if public sewer is <br /> Installation will serve: Residence Commercial ,.Other available within 200 feet.) <br /> Number of living units: —L Number of bedrooms:__...___ ' t <br /> Character of soil to a depth,of 3 feet: ? rC a>• ' <br /> SEPTIC TANKw� fi Water table depth <br /> Type/Mfg :. Capacity��t1 - patio. Compartments <br /> PKG. TREATMENT PLT. ❑ fes' w 1, ' <br /> r Method of OispoSal <br /> Distan'c'e to no r4if'.`".',WWII Foundation� _ /al <br /> Property Line <br /> LEACHING LINE "No'`'&'Lenyth of.I nes - <br /> FILTER BED f Total length/size <br /> ,,,,�❑,;�,Distance_to_nearest: Well I Foundation_ <br /> r Property Line _! <br /> f <br /> SEEPAGE PITS I I Depth , f <br /> SUMPS _ - Number <br /> 1:1,'-Distance to nearest: Well FoundationI` <br /> DISPOSAL PONDS - C7 Property Line <br /> �,. <br /> I hereby certify that./ have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,zstate laws, and <br /> rules and regulations of the San Joaquin Local-Healtb Diltrict.: <br /> f Home owner or licensed agent's signature certifies the following: <br /> certify tperformance <br /> � n e of the work for which r ermit i- <br /> employ any person in such manner as to become subject to woman's compensation laws of Cal California." Contractor's tohiririgor b-cos issued,ntrac nglsignatunot <br /> rre <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject'to.workman's compensa- <br /> tion laws of California." <br /> The applicant must caller all required inspections. Complete drawing on reverse side. <br /> Signed X_ �-f'r /� { <br /> "llff"" " `Title: � j <br /> Date; <br /> _ F R DEP RTftRENT SE ONLY } <br /> Application Accepted by <br /> Date a k <br /> Pit or Grout Inspection by pate <br /> Final Inspection b Date <br /> Additional Comments: '! <br /> ­O-Slk' 466=6781 '❑ Lodi 369-3621 ❑ Manteca 823-7104 - ..❑'Tracy M5-638!5- <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 ;A�MOUNT REMITTEDINFOCASHRECEIVED 8Y DATE PERMI7'NO. <br /> +,EH13-24fREV.1/H5) - W <br /> EH 14-2e <br />