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rr <br /> APPLICATION FOR PERMIT <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 /> Job Address oen 7 SinQ City Lot Size PM <br /> i � <br /> Owner's Name Address Ji � 1"f'� •rs 1 Phone <br /> Contractor_ � lL[s Address ' ► License N Phone fe <br /> TYPE OF WELL/PUMP: ��. NEW WELL ❑ WELL REPLACEMENT-0, DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑n I OTHER ❑ f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />'p FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS"'g'"" <br />` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing r ' 1 Specifications <br /> 1-1 Public Cl,Other Cl Delta Depth of Grout Seal "� " -. Type of Grout _ <br /> I I Irrigation —_..Approx. Depth { 1 Eastern —Surface Seal Installed by -- ----�*- <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 t <br /> Depth k Filler Material (Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESAiON, septic system permitted if public sewer is <br /> able within 200 feet.l <br /> Installation will serve: Residence Commercial F_. OtherNumber of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity t \No. Compartments <br /> i PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t <br /> 'Distance to nearest: Well Foundation Property Line ti <br /> �4 <br /> I LEACHING LINE ❑ :No. & Length of lines Total length/size, <br />' FILTER BED ❑ Distance to nearest: Well "- _r_0ZWdat6n­ R _ Property Line <br /> I SEEPAGE PITS 1 ) Depth t 1 ' Size Number_.' 1 <br /> SUMPS ❑ :Distance to nearest: Wel Foundation Property Line- <br /> DISPOSAL PONDS ❑ <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 Di1trict. �,::I.1:1� I <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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that 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 California." <br /> F <br /> The applicant must call for al re u' ins <br /> I pp q peCtions.'Complete drawing on reverse side. <br /> 4 , <br /> t Signed X Title: - Date: , <br /> ell7j% _ k"FOR DEPARTMENT:USI ONLY <br />' Application Accepted by Date t/ Area <br /> Pit or Grout Inspection by D Final Inspection by a Date <br />' Additional Comments: 1. 5 �—aY4 <br /> ❑ Stk 466-6781 ❑ Lod 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 /> G <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIVNO. <br /> INFO <br /> +.EH 1IREV. /H'55 .L, r <br /> EH 14-2a4-M <br />